Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Corvallis Manor Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Improper Refrigerated Medication Storage: The facility failed to safely store refrigerated meds in one medication refrigerator. The Administrator said temps were monitored electronically, but no abnormal-temp alerts were sent and the log was only checked weekly. Review of the refrigerator logs showed repeated temps below 36°F, including many hours below freezing, and the unit contained GLP injections, glargine insulin, insulin aspart, and a shingles vaccine. Ice crystals were seen on a glargine insulin vial bag, and the pharmacist stated the insulin, GLP, and vaccine were no good and needed to be discarded.
Failure to Develop and Implement Water Management Plan for Legionella Control: The facility did not develop or implement an effective water management plan to identify areas where water-borne pathogens could grow and spread. Records showed no documented water system risk assessment in the facility assessment or Legionella control plan, and the plan contained another facility's name. The Administrator and Maintenance Director stated they used a template from another facility, and the Administrator said staff believed there was nowhere pathogens could grow because water was always in use, but no documentation of that assessment was provided.
Failure to Offer Pneumococcal Vaccinations: The facility failed to offer pneumococcal vaccines to 4 sampled residents who were eligible based on age and/or chronic conditions, including heart failure, diabetes, and dementia. The Infection Preventionist LPN identified the residents as eligible but not yet offered the vaccine, the prior Infection Preventionist/LPN Resident Care Manager stated she had not had the chance to offer it, and the DNS stated she was unsure of the regulation for offering pneumococcal vaccination.
Failure to obtain consent for psychotropic dose changes: Two residents had psychotropic GDRs implemented without updated consent in the record. One resident with depression and HF had duloxetine reduced after a pharmacy recommendation, and the other resident with bipolar disorder and PTSD had trazodone reduced after an APRN order; staff and the DNS confirmed the facility did not have a consistent process for obtaining resident consent for dose decreases.
Resident areas and equipment were not kept in good repair for two residents. One resident with hx of hypo-osmolality, hyponatremia, TIA, weakness, and ROM impairment had ripped, peeling bed cane grips that had been damaged for months and were used for turning and repositioning in bed. Another resident with dementia, stroke, and hospice care had long-standing gouges and scraped paint on the wall behind the bed, which staff acknowledged had been present for a long time.
Failure to Provide Bed Hold Notices and Discharge Referral Information: The facility did not provide written bed hold notifications, including reserved bed hold payment details, when a resident with HF and DM was transferred to the hospital multiple times. The facility also did not ensure a cognitively intact resident with fractures and respiratory failure received a timely home health referral after discharge; records and staff statements showed the agency did not receive the referral from the facility until it was later completed by an NP.
Baseline Care Plan Missing Pain and Fracture Interventions: A resident admitted with a compression fracture of the spine, generalized weakness, and frequent severe pain did not have a baseline care plan that included care or interventions for pain prevention or fracture-related needs. The care plan addressed toileting, hygiene, mobility, and responding to pain complaints, but did not reference the resident’s fractured back. Later, a CNA moved the resident quickly in bed with a draw sheet, causing back pain and the resident to yell out; staff acknowledged the pain and that the care plan did not address the fractured back and associated pain.
A facility failed to fully individualize care plans for two residents with ADL needs. One resident with stroke-related weakness needed tray set-up on the left side and all food opened, but the care plan did not include those directions and trays were observed with items out of reach or unopened. Another cognitively intact resident who was dependent for toileting hygiene had skin irritation from facility wipes, yet the care plan did not reflect the resident’s preference for a warm wet washcloth and baby soap.
Inadequate Toileting Hygiene for a Dependent Resident: A cognitively intact resident who was incontinent of bowel and bladder and dependent on staff for perineal hygiene was found to have repeated episodes of feces left in the genital area after toileting care. The resident stated staff were not always thorough and did not feel fully clean, while multiple CNAs and an LPN reported observing inadequate hygiene and feces remaining after care; some concerns were not reported up the chain of command.
The facility failed to follow physician orders for a resident with CHF and DM by not notifying the provider after multiple overnight weight gains. It also failed to document and treat a skin tear promptly for another resident and did not administer an ordered antibiotic course as prescribed because the order was transcribed incorrectly.
A resident with ESRD and dependence on dialysis returned from dialysis with a left chest access site that was supposed to be monitored and documented by staff. The resident stated the nurse assessed the resident before dialysis but not after return, and observations showed no nurse entered the room for post-dialysis assessment for 45 minutes on one day and more than an hour on another day. A charge nurse later claimed the resident had been assessed, but this was inconsistent with direct observation.
A resident with stroke and HTN had an order for lisinopril 10 mg daily with instructions to hold it if systolic BP was under 120. Review of the MAR showed the CMA gave the medication multiple times when the resident’s systolic BP was below the ordered parameter, and the record contained no rationale for those administrations. The CMA acknowledged the error, and the LPN case manager confirmed the dates the medication was given outside the ordered limits.
Failure to provide cut up foods for a resident with stroke-related right-side weakness and impaired ROM who required set-up assistance for eating. The care plan and Kardex directed dining assistance, and the family reported the resident could only use one hand and needed all food cut up, but meal observations showed multiple trays with whole or large food items. Staff gave conflicting accounts about whether the kitchen or bedside staff were responsible, and the RCM acknowledged the care plan lacked clear instruction.
Surveyors found that the facility did not properly investigate two separate incidents involving two residents. In one case, a resident with muscle weakness and unsteadiness was found on the floor near an electric wheelchair after an unwitnessed fall, but the facility’s investigation lacked witness statements, a root cause analysis, and documentation ruling out abuse or neglect. In the other case, a resident with muscle weakness and diabetes reported a missing phone through a grievance and to the police, yet there was no documented investigation into how the phone went missing, and staff later acknowledged that such an investigation should have occurred.
A resident with a history of hip pain and a fractured thigh bone did not receive prescribed narcotic pain medication on multiple occasions due to medication unavailability and communication breakdowns between staff, providers, and the pharmacy. Documentation showed the resident experienced severe pain while awaiting the medication, and staff acknowledged delays in reordering and escalating the issue.
Two residents experienced significant delays in receiving care due to insufficient nursing staff and poor communication. One resident waited over 50 minutes for medication for constipation, while another, who was bedridden, waited 45 minutes for incontinence care and was told to wait until after meals. Staff confirmed these delays and the administrator acknowledged the expectation for call lights to be answered within 15 minutes.
A resident dependent on staff for toileting, with a history of stroke and language deficits, was left alone on the commode despite a care plan and posted instructions requiring staff presence. The assigned CNA was unaware of the updated care plan due to an unupdated Kardex, resulting in the resident experiencing distress and filing grievances regarding unmet needs and delayed assistance.
A resident with complex regional pain syndrome and anxiety did not receive prescribed eye drops due to unavailability, and a physician-approved substitution was delayed. Staff were aware of the medication shortage and the resident's repeated requests, but the new order was not implemented promptly, resulting in unmet care needs.
A resident with a history of stroke and language deficits, identified as a fall risk and dependent on staff for toileting, experienced a fall from the commode after the call light was not placed within reach as required by the care plan. Staff confirmed the call light was attached to the bed and not accessible, and the investigation into the incident was incomplete.
Two residents suffered significant injuries when staff failed to properly use a mechanical lift and did not follow care plan interventions. One resident fell headfirst from a Hoyer lift due to an unsecured sling strap, resulting in multiple brain and spinal injuries. Another resident, who required a two-person assist, was injured when a staff member provided care alone and failed to remove a broken call light clip, causing a skin tear and multiple bruises. Staff interviews and records confirmed that required safety checks and care plan protocols were not followed.
A resident with dementia and weakness was found with unexplained bruising, swelling, and pain in multiple areas. Staff assessed the injuries and notified supervisors, but did not complete a Facility Reported Incident (FRI) form or report the injuries as required. This failure to report and document the injuries of unknown origin resulted in a deficiency related to abuse and neglect reporting protocols.
The facility did not maintain proper food temperatures during meal service, resulting in cold and unpalatable meals for two residents, including one with cirrhosis and another with diabetes and malnutrition. Staff acknowledged equipment issues and residents reported dissatisfaction with food quality, including meals being served cold and not meeting dietary needs.
The facility failed to follow physician orders and implement care protocols for several residents, including missed administration of nutritional supplements and medications, lack of documentation for blood sugar checks, improper medication administration routes, delayed wound care due to unavailable supplies, and failure to monitor or address bowel and urinary issues. Staff interviews confirmed lapses in care, lack of timely physician notification, and unfamiliarity with required procedures.
A resident with cognitive impairment and mental health diagnoses was allowed to keep multiple medications in their room without proper assessment, monitoring, or documentation by staff. Staff did not consistently review administration instructions or track which medications the resident accessed or returned, resulting in unsecured medications and a lack of oversight.
A resident with cognitive capacity reported a missing cell phone to staff on multiple occasions, but no grievance was filed or assistance provided, despite staff awareness of the issue. Facility records confirmed no grievance was submitted, and staff interviews revealed a lack of knowledge about the grievance process and forms.
A resident with anxiety and PTSD was admitted and assessed through PASARR Level II, which recommended a recliner chair to address discomfort from prolonged wheelchair use. The recommendation was overlooked, and the resident did not receive the chair, with staff later acknowledging they were unaware of the PASARR guidance.
Two residents who required assistance with ADLs did not receive necessary personal hygiene care. One resident was repeatedly observed with long facial hair despite requesting its removal, and another resident with diabetes had long, dirty, and jagged fingernails, with required nail care not completed as scheduled. Staff interviews revealed confusion about responsibilities and a lack of direct assessment.
A resident with diabetes and vascular dementia developed redness and swelling of the left big toe, which was not properly monitored or evaluated as ordered. Documentation of physician orders and wound care was lacking, and the resident was discharged without the scheduled physician assessment. Upon admission to another facility, the resident was found to have an infected ingrown toenail with significant symptoms, confirming the lack of appropriate foot care and monitoring.
Water temperatures in both resident bathrooms and the therapy gym were found to be excessively high, with measurements reaching up to 141.6°F. Several residents with significant care needs, including those dependent on staff for toileting and mobility, were exposed to these unsafe conditions. Maintenance staff were unable to explain the discrepancy between boiler settings and actual water temperatures, and staff interviews confirmed that the issue had not been previously identified or addressed.
A resident with incomplete quadriplegia and a history of UTIs was allowed to self-catheterize without staff assessment or observation of their technique or hand hygiene. Staff set up supplies but did not verify if the resident performed the procedure in a clean manner, and there was no documentation of education or assessment related to infection prevention.
A resident with ESRD requiring hemodialysis did not have consistent completion of required Pre- and Post-Dialysis Assessment forms, with some forms missing vital information or left blank, and daily weights were not obtained or documented as ordered by the physician. Nursing staff and the DNS confirmed these lapses in communication and documentation between the facility and the dialysis provider.
A resident with dementia and a documented history of multiple forms of abuse was not provided trauma-informed care, as their care plan lacked interventions addressing trauma despite staff awareness of PTSD and behavioral concerns. The care plan focused only on cognitive impairment, and the resident's expressed interest in behavioral health support was not acted upon.
A resident on hospice care with cancer was provided with bilateral half bed rails without a documented assessment to determine safety risks or necessity. Staff interviews confirmed that required evaluations were not completed before the rails were applied, and maintenance and hospice staff were unaware of any assessment being conducted.
A resident with PTSD, agoraphobia, and bipolar disorder exhibited ongoing depressive symptoms, irritability, and refusal of care. Despite a physician's recommendation for a geriatric psychiatric referral, no mental health evaluation was documented or provided. Staff interviews confirmed the resident's continued isolation and refusal of care, and facility leadership acknowledged the lack of behavioral health services.
Three residents did not receive proper medication management, including a delayed dose reduction for a mood stabilizer, continued administration of a discontinued pain medication, and administration of an anti-hypertensive despite low blood pressure readings. Staff were unaware of or did not follow standing orders, and medication changes were not implemented as ordered.
A resident with kidney failure was evaluated for a suspected UTI, but the final urine culture results were not communicated to the physician for six days. During this time, the resident was not started on antibiotics and was not monitored for complications. Staff interviews confirmed the delay and acknowledged that timely follow-up was expected.
A resident admitted with a stroke diagnosis had blood samples collected and sent for thyroid hormone testing as ordered by a prescriber. The results of these tests were not found in the clinical record, and a consultant pharmacist noted the absence. An LPN unit manager confirmed the samples were sent but could not explain why the results were missing or why follow-up did not occur.
Two residents with special dietary needs did not receive requested or ordered menu items, including pizza and oatmeal, due to staff inaction and lack of process training. One resident's pizza request was not fulfilled after preparation, and another resident did not receive oatmeal listed on their breakfast ticket. Facility leadership confirmed that residents should receive the food items listed on their tickets.
A resident with incomplete quadriplegia and a history of UTIs continued to receive daily prophylactic trimethoprim even after a urine culture showed resistance to this antibiotic. The resident was also treated with amoxicillin for the acute infection, but the original antibiotic was not discontinued, and no provider documentation justified its continued use. Staff interviews confirmed the lack of appropriate antibiotic stewardship in this case.
Two residents experienced deficiencies in their living environment, including a fan with dusty blades and unresolved maintenance issues such as a non-functioning phone and room light. Staff reported delays in completing work orders, and one resident's family had to use 911 dispatch to contact them due to the broken phone. An LPN also had to use a cell phone light to provide wound care because the room light was out.
A resident with a Stage 3 pressure ulcer did not receive prescribed wound care and wound vac changes as ordered, due to staff not performing the treatment over a weekend. Staff initially cited a lack of supplies, but the unit manager confirmed the necessary materials were available. The missed treatment was not documented, and the physician was not notified.
A resident admitted with diabetes and a surgical site infection did not receive prescribed mealtime insulin upon arrival due to delays in pharmacy order processing and delivery. Nursing staff and the pharmacist confirmed that the medication request was submitted after the immediate delivery deadline, resulting in the resident's insulin being administered several hours late.
The facility did not consistently implement infection control precautions for three residents, including inconsistent use of gowns during catheter care, ongoing shortages of plastic bags, paper towels, and soap that impeded proper disposal of soiled linens and hand hygiene, and staff failing to use required PPE when entering a room of a resident on contact precautions. These actions and inactions were confirmed by staff, residents, and direct observation.
The facility failed to maintain the low temperature dish machine, risking foodborne illnesses. The dish machine's wash cycle temperatures were inadequate, leading to the use of paper products for meal service. Staff reported inconsistent water temperatures affecting both dishwashing and resident showers. Despite this, management instructed continued use of the dish machine, relying on chemical sanitizers. The issue was not addressed promptly, although a new hot water heater was ordered.
The facility failed to provide properly textured diets for two residents, one with Alzheimer's and another with a history of stroke. Both required pureed diets, but their meals contained improperly processed food, posing risks for aspiration. Staff acknowledged the inadequacy of the non-commercial food processor and the need for additional training.
The facility failed to provide sufficient nursing staff, resulting in delayed responses to resident call lights and unmet care needs. Observations and interviews revealed residents experiencing long wait times for assistance, with some waiting up to an hour. Resident Council Notes and witness statements confirmed ongoing staffing issues, particularly on weekends, affecting the timely provision of care.
Meals in the facility were not served at the proper temperatures, with eggs and milk failing to meet FDA guidelines. Residents and staff reported that meals were often late and cold, with one resident noting cold meals 75% of the time. A breakfast test tray confirmed the deficiency, with eggs at 91 degrees F and milk at 45 degrees F. Staff acknowledged the consistent issue of cold, unseasoned food served late.
The facility failed to maintain a safe and homelike environment in two resident rooms, where walls were in disrepair and baseboard coving was missing. This allowed outside air and cigarette smoke to enter the rooms, as confirmed by residents and staff. The issue was acknowledged by the facility's administrator and social service director, who noted that maintenance was aware and other rooms were similarly affected.
A resident with a left femur fracture was neglected in a facility, leading to a fall and subsequent hospital visit. The resident was found on the floor without footwear and with a soiled brief, having not been assisted with toileting for several hours. Staff interviews confirmed the resident's bed linens were soaked with urine and feces, and the resident had not received incontinence care all morning. The facility's investigation substantiated neglect of care.
The facility did not staff an RN for eight consecutive hours per day, seven days a week, for 22 out of 91 days reviewed. This deficiency was confirmed through interviews and record reviews, revealing specific days in January, February, and March 2024 without adequate RN coverage. The Administrator and DNS acknowledged the issue, which placed residents at risk for unmet assessment needs.
Improper Refrigerated Medication Storage
Penalty
Summary
The facility failed to ensure medications were safely stored with proper temperature monitoring for 1 of 2 refrigerators reviewed for medication storage. During interview, Staff 1, the Administrator, stated refrigerator temperatures were monitored through digital temperatures sent to an electronic application every hour, but the system did not send alerts for abnormal temperatures and he checked the application weekly. Staff 2, the DNS, stated that if refrigerated medications were exposed to temperatures outside the safe range, the medications needed to be disposed of. Review of the New Wing medication refrigerator temperature logs showed temperatures below 36 degrees Fahrenheit on 19 of 30 days reviewed, with multiple hours below freezing and lows as low as 17.5 degrees Fahrenheit. On observation, the refrigerator contained nine GLP injections, 29 glargine insulin pens, one glargine insulin vial, 10 insulin aspart pens, one insulin aspart vial, and one shingles vaccine. Ice crystals were observed on the glargine insulin vial bag. The pharmacist reviewed the temperature logs and stated that with that many hours under freezing, the insulin, GLP, and vaccine were no good and needed to be discarded.
Failure to Develop and Implement Water Management Plan for Legionella Control
Penalty
Summary
The facility failed to develop and implement an effective water management plan to identify potential areas of growth and spread of water-borne pathogens and illness. A review of the facility's 3/2023 Infection Prevention and Control- Legionnaire's Disease Policy stated that Legionnaires' Disease is caused by Legionella pneumophila and that specific actions should be taken for prevention and for investigation if a case occurs. However, a review of the facility's 12/30/25 Facility Assessment showed no evidence that a risk assessment was completed to prevent the growth and spread of water-borne pathogens in the main water system. A review of the facility's 1/22/26 Risk Management plan for Legionella Control showed no facility water system assessment identifying potential areas of growth and spread of water-borne pathogens and no risk analysis assessment with control measures to prevent opportunistic waterborne pathogens. The plan also contained another facility's name throughout the document. On 5/11/26, the Maintenance Director and Administrator stated they had been provided a template Risk Management Plan for Legionella Control from another facility and could not remove the other facility's name, although the Administrator stated he updated the information to reflect their facility. The Administrator also stated staff identified there was nowhere water-borne pathogens could grow because the water was always in use and the facility never had an empty resident room, but no documentation of that assessment was provided. The Administrator further stated Legionella control was not part of their Risk Management plan.
Failure to Offer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure residents were offered pneumococcal vaccines for 4 of 5 sampled residents reviewed for vaccines. The facility’s revised 8/2024 Infection Prevention and Control-Influenza and Pneumococcal Immunizations policy stated that residents 65 years of age and older, and residents ages 19-64 with chronic medical conditions or other risk factors who had not previously received PCV or whose vaccination history was unknown, are to be offered pneumococcal vaccination per current CDC recommendations, and that the resident record should reflect education, administration or refusal, or non-administration due to medical contraindication. Resident 7, admitted in 2021 with heart failure, was eligible for but was not offered a pneumococcal vaccine. Resident 13, admitted in 2024 with heart failure, was also eligible for but was not offered a pneumococcal vaccine. Resident 18, admitted in 2021 with diabetes, was eligible for but was not offered a pneumococcal vaccine. Resident 34, admitted in 2024 with dementia, was eligible for but was not offered a pneumococcal vaccine. Staff 12, the Infection Preventionist LPN, stated she identified these residents as eligible but not yet offered the vaccine. Staff 6, the prior Infection Preventionist and LPN Resident Care Manager, stated she never had the chance to offer the pneumococcal vaccination to eligible residents. Staff 2, the DNS, stated she was unsure what the regulation was to offer residents the pneumococcal vaccination.
Failure to Obtain Consent for Psychotropic Dose Changes
Penalty
Summary
The facility failed to obtain consent from residents when psychotropic medication doses were changed for two sampled residents. The facility’s revised psychotropic medication policy stated that the resident or resident representative would be informed in advance of the risks and benefits of proposed care, treatment alternatives or other options, and the preferred option to accept or decline in a format the facility used. For one resident, admitted with depression and heart failure and cognitively intact with a BIMS of 15, consent had been obtained for duloxetine 60 mg twice daily, but after a pharmacy recommendation for a gradual dose reduction, the provider changed the order to duloxetine 90 mg once daily and the medication was administered starting the next day without an updated consent in the record. The resident stated the facility did not talk to him/her about the decrease in the antidepressant medication, and the DNS confirmed there was no consent for the dose change. For the second resident, admitted with bipolar disorder and PTSD, a pharmacy recommendation identified a gradual dose reduction for trazodone, and the APRN signed the order after a progress note indicated the GDR was discussed during a visit. However, the resident stated he/she was not aware he/she took trazodone, staff were unsure when or by whom the GDR had been reviewed with the resident, and the medical record contained no updated consent form after the dose reduction. The DNS stated staff were expected to discuss GDRs with residents or resident representatives before initiating them, but consent was only obtained when psychotropic doses were increased, not decreased.
Resident Areas and Equipment Not Kept in Good Repair
Penalty
Summary
The facility failed to ensure resident areas and equipment were in good repair for two sampled residents. Resident 30, who was admitted with diagnoses including hypo-osmolality, hyponatremia, and transient cerebral ischemic attack, had a care plan indicating the resident was bedridden and required a high level of caregiver support due to general muscle weakness and muscle atrophy. The quarterly MDS also indicated one-sided upper body range of motion impairment and need for assistance with transfers and mobility. During observation, the resident’s bed cane grips were seen ripped and peeling on both sides of the bed, and the resident stated the bed canes were used when turning in bed and could not recall a time when the grips were not damaged. A CNA stated the resident frequently used the bed canes for turning and repositioning and acknowledged the grips had been in that condition for a couple of months. The Maintenance Director confirmed the bed canes were damaged and needed replacement. Resident 34, who was admitted with diagnoses including dementia and stroke, had an annual MDS showing hospice care. In the resident’s room, three long gouges and scraped paint were observed behind the head of the bed. A CNA stated the wall damage was old and had been there a very long time. The Maintenance Director stated resident rooms were inspected monthly for repair needs and that painting and touch-ups were done frequently, but acknowledged the wall damage in the room and stated it had been there for a long time and was not repaired because the resident was in the room.
Failure to Provide Bed Hold Notices and Discharge Referral Information
Penalty
Summary
The facility failed to provide written bed hold notifications, including reserved bed hold payment information, when a resident was transferred to the hospital on multiple occasions. Resident 4 was admitted with diagnoses including heart failure and diabetes and was transferred to the hospital on 1/2/26, 1/22/26, 2/13/26, and 3/6/26. The clinical record did not show that the resident or the resident’s representative received written notice of the facility’s bed hold policy at the time of transfer. Staff stated that the charge nurse explained the bed hold policy and cost at transfer and that the discussion would be documented, but the DNS confirmed that written bed hold notification was not provided for those transfers. The facility also failed to provide appropriate information to a provider for Resident 96 related to discharge and home health services. Resident 96 was admitted with diagnoses including fractures of the right arm and right thigh and respiratory failure, had a BIMS score of 15, and was documented as improving and appropriate for discharge with home health arranged. Records showed the resident was discharged in stable condition, but later documentation and interviews indicated the home health agency did not receive a referral from the facility. Staff acknowledged no email for home health services was found for the resident, the agency did not receive a referral until it was later completed by a provider, and the DNS acknowledged the facility did not ensure the resident received home health services after discharge.
Baseline Care Plan Missing Pain and Fracture Interventions
Penalty
Summary
The facility failed to implement a baseline care plan with required care and interventions for Resident 105 within 48 hours of admission. Resident 105 was admitted in 4/2026 with diagnoses including a compression fracture of the spine and muscle weakness. The 4/13/26 admit visit progress note identified the chief complaint as compression fracture of the spine and generalized weakness. The 4/14/26 admission MDS and associated CAA showed the resident reported frequent severe pain, had sustained a compression fracture of the spine from a fall, and had a BIMS score of 13, indicating the resident was cognitively intact. The resident was at risk for unrelieved pain. The 4/17/26 baseline care plan addressed staff assistance for toileting and hygiene, risk for pain related to chronic pain, limited physical mobility, and instructions for staff to respond to complaints of pain and report decreases in functional abilities. However, it did not include reference to prevention of pain or care related to the resident’s compression fracture of the spine. On 4/22/26, Resident 105 reported that a CNA moved the resident quickly in bed, used a draw sheet, and jerked the resident’s back, causing pain and prompting the resident to yell out. The resident also stated the movement was painful and that the CNA did not follow verbal direction for care. Staff later acknowledged the resident experienced pain because of the care provided, and the DON acknowledged the care needed to address the fractured back and associated pain was not in the care plan.
Failure to Individualize Care Plans for Eating Assistance and Toileting Hygiene
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents reviewed for ADLs. One resident had a history of stroke, chronic pain, right-side weakness, impaired range of motion on one side, and required set-up assistance for eating. Although the resident’s care records and Kardex indicated assistance with dining and tray set-up, the care plan did not include directions to place food items and utensils on the resident’s left side or to ensure all food packaging was opened. Survey observations showed meal trays with items placed out of reach on the right side, including fruit salad, oatmeal with the lid on, and unopened butter and jelly packets, while a family member stated the resident could only use the left hand for eating and needed all items opened and positioned on the left side. The other resident had bilateral lower limb reduction defects and weakness, was cognitively intact, and was incontinent of bowel and bladder with dependence on staff for perineal hygiene and brief changes. The care plan directed staff to assist with toileting hygiene and keep the resident’s skin clean and dry, but it did not include the resident’s preference for using a warm wet washcloth and baby soap instead of facility wipes. The resident and multiple staff members stated the facility wipes caused skin irritation or burning, and staff reported that washcloths had been used to reduce irritation, but this information was not reflected in the care plan. Staff and management acknowledged that the resident’s toileting hygiene preferences should have been included in the care plan.
Inadequate Toileting Hygiene for Dependent Resident
Penalty
Summary
The facility failed to ensure a dependent resident received assistance with toileting hygiene. Resident 82 was admitted with diagnoses including bilateral lower limb reduction defects and weakness. The admission MDS dated 4/9/26 indicated the resident had a BIMS score of 15 and was cognitively intact. The same MDS showed the resident was incontinent of bowel and bladder and dependent on staff for perineal hygiene and brief changes. The care plan dated 4/3/26 directed staff to provide assistance with toileting hygiene and keep the resident's skin clean and dry. During interviews, Resident 82 stated staff were not always thorough with toileting hygiene and that the resident did not feel fully clean after bowel incontinence episodes, with redness to the skin. Staff 17, Staff 18, Staff 19, and Staff 22 each reported observing feces left in the resident's genital area during toileting hygiene or after brief changes, and some stated this had occurred more than once. Staff 17 said the issue was not reported to the nurse, Staff 21 said he heard about the concern but did not report it to the Resident Care Manager or DNS, and Staff 4 and Staff 2 stated they were not aware the resident was receiving inadequate toileting hygiene care.
Failure to Follow Orders for Weights, Wound Care, and Antibiotics
Penalty
Summary
The facility failed to follow physician orders and failed to document or provide necessary wound care for two residents. One resident, admitted with diagnoses including heart failure and diabetes, had a physician order to check weight daily and notify the provider for a 3-pound overnight gain or a 5-pound gain within a week. The resident had multiple overnight weight gains documented on the TAR, including gains of 4.2 pounds, 7 pounds, 5.2 pounds, and 4.2 pounds, but the medical record showed no indication the provider was notified of any of these weight gains. Staff later confirmed the provider was not notified, and the DNS stated staff were expected to follow the physician's order. Another resident, admitted with diagnoses including heart failure and diabetes, had a skin tear on the left arm that was reported by family and later acknowledged by staff as not being documented or treated until days later. A complaint alleged the facility failed to treat and document the wound, and staff stated an agency nurse found the skin tear but did not document it or start treatment until another nurse identified it later. The same resident also returned from the emergency department with an order for antibiotics twice a day for 10 days, but the MAR showed the antibiotic was given only for part of the ordered course and then again on later dates. The DNS acknowledged the antibiotic was not administered as prescribed because the order had been transcribed incorrectly as 10 doses instead of 10 days.
Delayed Post-Dialysis Assessment and Documentation
Penalty
Summary
The facility failed to provide immediate monitoring and documentation of a resident’s dialysis access site after return from dialysis treatment. The resident was admitted with end-stage renal disease and dependence on dialysis, had a care plan for dialysis three times weekly, and had a left chest dialysis access site that staff were to monitor and document for infection or complications. The physician’s order required staff to complete the post-dialysis assessment form when the resident returned from dialysis and to ensure the pre-dialysis and communication forms were returned with the resident. On one occasion, the resident returned from dialysis around 10:00 AM and stated that the nurse had assessed the resident before leaving for dialysis but had not assessed the resident upon return. The resident was observed in the room for 45 minutes without a nurse entering to complete a post-dialysis assessment. On another dialysis day, the resident again returned from dialysis and stated that no nurse had assessed the resident after return; the room was observed for more than an hour without a nurse entering to assess the resident post-dialysis. A charge nurse later stated she had assessed the resident, but this was inconsistent with the observation. The DNS stated standard of care was a couple of hours after returning from dialysis, and later acknowledged the findings.
Lisinopril Given Outside Ordered Blood Pressure Parameters
Penalty
Summary
The facility failed to ensure adequate monitoring and indications for use of lisinopril for one resident with diagnoses including stroke and hypertension. The resident had a physician order for lisinopril 10 mg by mouth daily for hypertension, with instructions to hold the medication if systolic blood pressure was less than 120. Review of the March 2026 and April 2026 MARs showed the resident received lisinopril multiple times when the systolic blood pressure was below 120, and all of those administrations were given by a CMA. The clinical record contained no rationale for giving lisinopril outside the ordered parameters. On interview, the CMA acknowledged administering the medication outside the blood pressure parameters and was unable to provide a rationale, and the LPN resident case manager confirmed the dates when the medication was given outside the ordered parameters.
Failure to Provide Cut Up Foods for a Resident Needing Dining Assistance
Penalty
Summary
The facility failed to provide cut up foods for Resident 84, who was admitted with diagnoses including stroke and chronic pain and had documented right-side weakness and impaired range of motion. The resident’s care plan and MDS indicated the resident required assistance with eating and set-up support, and the Kardex directed staff to provide dining assistance such as cutting up food. At the 4/22/26 quarterly care conference, the family member stated the resident needed food cut up because the resident could not cut food independently. On 5/4/26, the family member stated the resident could only use the left hand for eating and required all food items to be cut up, and also said a sign had been placed in the room to remind staff. Meal observations showed the resident received a lunch tray with a cut up burger patty inside a whole bun, a breakfast tray with full slices of bacon and a whole piece of frittata, and a lunch tray with large chunks of chicken and potato and whole asparagus spears. Staff later stated the resident’s food was supposed to be cut up by kitchen staff, while the resident care manager acknowledged staff were to cut the resident’s food at bedside and that the care plan did not provide clear instruction to cut the resident’s food.
Failure to Investigate Unwitnessed Fall and Missing Personal Property
Penalty
Summary
The deficiency involves the facility’s failure to conduct a complete investigation of an unwitnessed fall for one resident. This resident was admitted with muscle weakness and unsteadiness on feet, and a public complaint alleged that the resident slept in a wheelchair and slipped out onto the floor. The facility’s unwitnessed fall investigation from that night documented that staff found the resident seated on the floor with the electric wheelchair positioned behind the resident at 12:20 AM, but the investigation lacked witness statements, a root cause analysis, and documentation confirming whether abuse or neglect had been ruled out. A registered nurse later stated she typically completed investigations for risk management but did not recall completing this unwitnessed fall investigation, and administration confirmed the investigation should have contained a root cause analysis, witness statements, and documentation excluding abuse or neglect. The deficiency also includes the facility’s failure to investigate a report of misappropriation of property for another resident. This resident, admitted with muscle weakness and diabetes, reported through a grievance that a phone that had been plugged in went missing around 1:00 AM, and a public complaint indicated the resident reported the missing phone to the police. Review of the clinical record showed no documentation of any investigation into the missing phone. The Social Services Director stated that an investigation should have been completed and noted the grievance focused on replacing the phone rather than determining how the phone went missing, and administration confirmed that an investigation into the missing phone should have been completed.
Failure to Provide Ordered Pain Medication Due to Communication and Refill Delays
Penalty
Summary
A resident admitted with right hip pain and a fractured thigh bone was prescribed hydrocodone-acetaminophen for pain management, to be administered every eight hours as needed for up to five days. Despite these orders, there were multiple documented instances where the resident did not receive the prescribed narcotic pain medication due to it being not available (NA) on the medication administration record (MAR). Specifically, doses were missed on several occasions, and staff notes indicated that the resident experienced severe pain during this period without access to the ordered medication. The deficiency was further compounded by communication issues between facility staff, the provider, and the pharmacy. Staff reported delays in reordering the medication and acknowledged that not all nurses had access to the provider communication system, making it the responsibility of Unit Managers to follow up on medication orders. The Director of Nursing confirmed that a refill for the narcotic medication was not sent to the pharmacy as required, and staff were expected to escalate such issues to management for resolution. These lapses resulted in the resident being without necessary pain medication for an extended period.
Delayed Response to Resident Needs Due to Insufficient Nursing Staff
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents in a timely manner, as evidenced by delays in responding to call lights and providing necessary care for two residents. One resident with a history of stroke and dementia was left waiting for assistance for over 50 minutes after requesting medication for constipation, despite a care plan directing staff to check on the resident frequently. The delay was attributed to poor communication between staff and low nurse staffing, with an agency CNA failing to promptly relay the medication request to the appropriate staff member. Another resident, who was bedridden and dependent on staff for all self-care, experienced a 45-minute wait for assistance with a brief change after activating the call light. The resident reported being told by staff to wait until after meals for incontinence care, which made the resident feel undignified. Staff confirmed the resident's dependence and preference for being changed before meals, and acknowledged the ongoing nature of the concern. The administrator stated that call lights were expected to be answered within 15 minutes and recognized the need for further investigation into the delays.
Failure to Provide Required ADL Assistance During Toileting
Penalty
Summary
A dependent resident with a history of stroke and language deficits, who was cognitively intact and required two staff for toileting assistance, did not receive the necessary assistance with activities of daily living (ADLs). The resident was admitted with a care plan indicating the need for staff to remain present while on the commode. Despite this, a grievance was filed after the resident was left on the commode for 30 minutes, and the resident specifically requested not to be left alone. The care plan was revised to reflect this preference, and signage was posted in the resident's room instructing staff not to leave the resident alone on the commode. However, staff interviews revealed that the CNA assigned to the resident was unaware of the updated care plan and the requirement to remain with the resident, as the Kardex had not been updated following a recent fall. During a time when the CNA was assisting another resident, other staff were instructed to assist, but the resident still experienced a delay in assistance and reported distress. The facility's investigation into the grievances did not identify the staff involved, and there was an expectation from leadership that the Kardex should have been updated and a thorough investigation conducted.
Failure to Provide Timely Eye Treatment per Physician Orders
Penalty
Summary
The facility failed to follow physician orders for eye treatments for one resident with complex regional pain syndrome and anxiety. Upon admission, the resident had a physician order for Optase (Glycerin) Comfort Dry Eye Solution to be applied twice daily. However, the medication was not available or on order from 7/2/25 through 7/10/25, and the resident did not receive the prescribed treatment during this period. Documentation shows that the resident repeatedly requested the eye drops, which increased their anxiety, and staff communicated with the pharmacy and the provider regarding the unavailability of the medication. On 7/7/25, a request was made to substitute the prescribed Optase with house stock Systane, and the physician approved this change. However, the new order for Systane was not implemented until 7/9/25, resulting in a delay in providing the necessary eye treatment. Staff interviews confirmed awareness of the medication shortage and the lack of a timely system to report or resolve missing medications. The delay in obtaining and administering the prescribed or substitute eye drops did not meet staff expectations and resulted in the resident's needs not being met as ordered.
Failure to Follow Fall Prevention Care Plan Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to follow a resident's care plan designed to prevent falls. The resident, who had a history of stroke and language deficits, was assessed as being at risk for falls and required the call light to be within reach at all times. Despite this, the resident experienced an unwitnessed fall from the commode, which was later attributed to the call light not being accessible. Staff interviews and documentation confirmed that the call light was attached to the resident's bed and not near the resident at the time of the incident. Further review revealed that the investigation into the fall was incomplete, lacking information about the cause or a conclusion. The resident reported being left on the commode for 30 minutes and specifically requested not to be left unattended. Multiple staff members, including an LPN and a CNA, acknowledged that the care plan was not followed, and facility leadership confirmed that the expected protocols were not adhered to in this case.
Failure to Prevent Accidents Due to Improper Use of Mechanical Lift and Non-Adherence to Care Plans
Penalty
Summary
The facility failed to ensure proper use of a mechanical lift (Hoyer) and adherence to care plan interventions, resulting in significant injuries to two residents. In one instance, a resident with Parkinson's disease and congestive heart failure, who was cognitively intact and required a two-person assist with a Hoyer lift, was being transferred from a raised bed to a shower chair. During the transfer, only three of the four sling straps were attached to the Hoyer, causing the resident to fall headfirst to the floor. The resident sustained a subarachnoid hemorrhage, intraparenchymal hemorrhage, scalp hematoma, and multiple compression fractures in the thoracic and lumbar spine. Staff interviews and observations confirmed that the sling was not properly secured, and the required safety checks were not performed prior to the transfer. In another case, a resident with dementia, weakness, and reduced mobility, who was severely cognitively impaired and required a two-person assist for turning and repositioning, suffered multiple injuries due to improper care. Staff failed to follow the care plan by attempting to provide care alone and not removing a broken, sharp call light clip from the resident's gown. This resulted in a skin tear on the resident's neck, bruising on the chest and right leg, and swelling and bruising on the left hand. Staff interviews revealed that the call light clip caused the skin tear when the blanket was pulled, and the resident was turned and dressed by a single staff member, contrary to the care plan. Both incidents were acknowledged by facility leadership, and documentation confirmed that the care plans and safety protocols were not followed, directly leading to the residents' injuries. The findings were based on observations, staff and resident interviews, and record reviews, which consistently indicated lapses in supervision and failure to prevent accident hazards as required.
Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report injuries of unknown origin for one resident who was admitted with dementia and weakness and required two-person assistance for turning and repositioning. On a specific date, staff observed the resident with bruising and discoloration on the right lower leg, swelling around the left hand, pain at the shoulder, and additional discoloration around the chest, none of which had been present the previous day. Staff members assessed the injuries and notified supervisory staff, but did not determine the cause of the bruising, and the resident was unable to describe how the injuries occurred. Despite the concerning findings, no Facility Reported Incident (FRI) form was completed for the resident. Staff involved acknowledged that an FRI form was not filled out, and one staff member stated she had never completed such a form before. The lack of timely reporting and documentation of the injuries of unknown origin constituted a failure to follow required abuse and neglect reporting protocols.
Failure to Maintain Safe and Appetizing Food Temperatures
Penalty
Summary
The facility failed to ensure that food temperatures were properly maintained during meal service, resulting in meals being served cold and unpalatable to residents. Observations during a lunch meal service revealed that the oven temperature was not maintained, causing delays in food preparation. Multiple undelivered lunch trays were stacked on top of an insulated cart due to insufficient space, and when a test tray was sampled, the food items were not warm and the pork was tough to cut. Staff acknowledged that the kitchen lacked sufficient and functioning equipment to keep food hot and of acceptable quality. Two residents were directly affected by these deficiencies. One resident, with a history of cirrhosis of the liver and high blood pressure, reported that mashed potatoes were soupy, broth was overly salty, and meals intended to be hot were served cold. This resident expressed dissatisfaction with the meals and reported going to bed hungry due to poor food quality. Another resident, diagnosed with diabetes and protein-calorie malnutrition, also reported that hot food was sometimes served cold. Staff confirmed these concerns and verified that residents should receive hot food at appropriate temperatures.
Failure to Follow Physician Orders and Implement Care Protocols
Penalty
Summary
The facility failed to follow physician orders, implement bowel care, and properly treat and monitor skin conditions for multiple residents, resulting in unmet needs. For one resident with a PEG tube and NPO status, staff did not consistently administer a physician-ordered nutritional supplement (Juven) as documented in the MAR, with several missed doses and no explanation provided in the clinical record. Additionally, blood sugar checks were not consistently documented, and there was a failure to clarify conflicting orders regarding the administration route for loperamide, with staff administering the medication through the G-tube despite the order specifying oral administration. Another resident with diabetes received fast-acting insulin significantly before a meal was provided, contrary to best practice and the medication's instructions, and was not given a snack to mitigate the risk of hypoglycemia. Staff acknowledged the delay in meal service and the lack of a snack, and the resident reported eating over an hour after insulin administration. For a resident with kidney failure, staff did not monitor for signs and symptoms of a UTI as ordered after the resident declined antibiotics, and there was no documentation of monitoring for complications, with staff confirming the lack of follow-up and unclear processes for physician notification. A resident with heart failure and end-stage kidney disease experienced an absence of bowel movements for eight days without evidence of monitoring, assessment, or implementation of bowel care protocols, and staff delayed notifying the physician and failed to ensure bowel care orders were in place upon admission. Another resident with diabetes and a surgical site infection did not receive timely wound vac treatment due to unavailable supplies and staff unfamiliarity with the wound vac process, resulting in missed and delayed wound care as documented in the treatment administration record and staff interviews.
Failure to Assess and Monitor Safe Self-Administration of Medications
Penalty
Summary
The facility failed to properly assess and monitor a resident for safe self-administration of medication. The resident, who had diagnoses including somatization disorder and PTSD, was determined by staff to have cognitive impairment and was not considered a candidate for unsupervised self-administration of medications. Despite this, the care plan allowed the resident to check out one medication per day to keep in their room, with staff expected to review administration instructions and document the resident's acknowledgment. However, there was no documentation in the clinical record indicating that staff reviewed instructions or that the resident checked out medications as required. Observations revealed that the resident had multiple nasal sprays and supplements in their room, both on the bedside table and in a large plastic tote. The resident stated they were allowed to keep medications in their room if kept organized. Staff interviews confirmed that the resident was permitted to keep certain medications at the bedside during the day but that staff did not monitor which medications were taken or returned, nor did they ensure medications were properly secured. The DNS acknowledged that the resident was not capable of safe self-administration and that staff were expected to follow the care plan, but these procedures were not followed.
Failure to Act on Resident Grievance for Missing Property
Penalty
Summary
The facility failed to ensure that a resident's grievance regarding missing property was acted upon in a timely manner. A resident admitted with fractures of the spine and pelvis, and documented as cognitively intact, reported her/his red cell phone missing on two occasions. Although the resident stated that staff were aware of the missing phone, no staff offered assistance to file a grievance, and the resident ultimately purchased a replacement phone. Review of facility grievance records showed no grievance form was submitted for the missing phone. Staff interviews confirmed awareness of the missing phone but revealed that no grievance was filed, and at least one staff member did not know where to locate a paper grievance form to assist the resident.
Failure to Implement PASARR Level II Recommendations for Resident with Mental Health Needs
Penalty
Summary
The facility failed to incorporate the PASARR Level II recommendations for a resident admitted with anxiety and post-traumatic stress disorder (PTSD). The PASARR Level II Mental Health Evaluation recommended providing a recliner-style chair for the resident, who reported discomfort from spending most of the day and night in a wheelchair and expressed a preference for sleeping in a recliner, as was their practice prior to admission. Despite this documented recommendation, the resident did not receive a recliner chair and had not received any updates regarding the request. Staff responsible for reviewing PASARR Level II results were unaware of the recommendations, and upon review, acknowledged that the recommendation had been overlooked.
Failure to Provide Required ADL Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents who required support. One resident, admitted with a history of stroke and muscle weakness and assessed as cognitively intact, required substantial to maximal assistance with personal hygiene. Despite care plans indicating the need for extensive support, this resident was repeatedly observed with significant facial hair and expressed a desire for its removal, stating that requests to staff had not resulted in the care being provided. Staff confirmed the presence of facial hair and acknowledged that it should have been addressed. Another resident, admitted with diabetes and also cognitively intact, required extensive assistance for bathing and hygiene, including diabetic nail care to be performed every two weeks. Observations revealed this resident had long, dirty, and jagged fingernails, and documentation showed that scheduled nail care was not completed as required. Staff interviews indicated confusion regarding responsibility for nail care, with CNAs and nurses each deferring to the other, and no direct assessment of the resident's nails was performed by the nurse responsible. The lack of proper nail care was confirmed by both observation and documentation.
Failure to Provide Appropriate Foot Care and Monitoring
Penalty
Summary
A resident with diabetes and vascular dementia was admitted to the facility and later developed redness and swelling of the left big toe, which was noted during an alert assessment. The area was cleansed, and the physician was notified, with instructions to monitor and provide supportive care. The resident was scheduled for a physician evaluation, but there was no documentation of monitoring or evaluation of the toe in the clinical record. Staff reported receiving a physician order for Epsom salt soaks, but no such order or wound evaluation was documented. The resident was subsequently discharged to another facility without evidence of the toe being evaluated by the physician as scheduled. Upon admission to the new facility, the resident was found to have an ingrown toenail with signs of infection, including increased drainage, pain, redness, inflammation, and eschar. The wound was measured and assessed as infected, and the physician at the new facility was notified. Interviews with staff and the physician confirmed that the toe was not evaluated as planned and that there was a lack of treatment and monitoring prior to discharge. Facility leadership acknowledged that the resident should have received treatment, monitoring, and physician observation of the wound before discharge.
Unsafe Water Temperatures in Resident and Therapy Areas
Penalty
Summary
The facility failed to ensure that water temperatures in resident areas and the therapy gym were maintained at safe levels, resulting in water temperatures that were significantly above recommended limits. Observations revealed that the water temperature in a shared resident bathroom reached 122 degrees Fahrenheit, despite the boiler being set at 114 degrees Fahrenheit. Maintenance staff were unable to explain the discrepancy between the boiler setting and the actual water temperature. Additionally, documentation showed that the water temperature in the physical therapy gym was recorded at 141.6 degrees Fahrenheit. Staff interviews confirmed that water temperatures were checked weekly, but there was no indication that the excessively high temperatures had been identified or addressed prior to the survey. Three residents with significant care needs, including those with heart disease, diabetes, and cancer, were identified as being at risk due to their dependence on staff for toileting and mobility. Staff interviews indicated that residents had not reported concerns about hot water, and in one case, it was noted that a resident did not use the affected bathroom. However, the presence of excessively hot water in both resident and therapy areas was confirmed through direct measurement and documentation, placing residents at risk for burns.
Failure to Assess and Monitor Resident's Self-Catheterization Practices
Penalty
Summary
The facility failed to assess a resident's ability to self-catheterize in a manner that would prevent urinary tract infections (UTIs). The resident, who had incomplete quadriplegia and a history of multiple UTIs, was able to move their arms but lacked fine motor function. Staff routinely set up catheter supplies for the resident but did not observe or assess the resident's technique or ability to maintain proper hand hygiene during the self-catheterization process. The care plan did not include specific instructions for staff to ensure a clean environment or to verify that the resident performed hand hygiene prior to catheterization. Multiple staff members, including CNAs, RNs, and LPNs, confirmed that they had not observed the resident perform self-catheterization or hand hygiene, and no documentation or assessment was available to demonstrate that the resident was able to perform the procedure safely. The bedside table was observed to have catheter supplies and a urinal, but no hand sanitizer was present. Despite the resident's history of UTIs related to self-catheterization, there was no evidence of education or assessment regarding infection prevention provided to the resident.
Failure to Ensure Accurate Dialysis Communication and Daily Weight Monitoring
Penalty
Summary
The facility failed to ensure accurate communication and documentation between the facility and the dialysis provider for a resident with end stage renal disease (ESRD) who required hemodialysis. Physician orders required staff to complete and send Pre- and Post-Dialysis Assessment and Communication forms with the resident to dialysis on specified days. Review of these forms revealed that some were incomplete, missing vital information such as post-dialysis vitals, comments, and signatures, while others were left entirely blank. Interviews with nursing staff and the Director of Nursing Services confirmed that the forms were not consistently completed or followed up on as required. Additionally, the facility did not obtain and document daily weights for the resident as ordered by the physician. Several days were identified where no weights were recorded, and staff interviews revealed uncertainty about the frequency of weighing the resident and the process for communicating this information. The Director of Nursing Services acknowledged that the resident's weights were not obtained daily as ordered, confirming a failure to follow physician instructions for monitoring the resident's condition.
Failure to Provide Trauma-Informed Care for Resident with History of Abuse
Penalty
Summary
A resident with a history of trauma, including suspected financial, sexual, verbal, emotional, and physical abuse, was admitted with diagnoses of psychotic disturbance, mood disturbance, and vascular dementia. The resident's care plan, revised after admission, addressed cognitive impairment and communication strategies but did not include interventions specific to trauma-informed care. Despite documentation from social services and an external physician noting the resident's trauma history and interest in behavioral health support, there was no evidence that trauma-specific needs were assessed or addressed in the care plan. Staff interviews revealed awareness of the resident's PTSD and behavioral responses, such as being jumpy and expressing fear during care activities. However, the Director of Social Services indicated no updates were received regarding the abuse investigation and did not consider the resident appropriate for counseling. Facility leadership confirmed that the care plan should have been individualized to address the resident's trauma history, but this was not done, resulting in a failure to provide trauma-informed care.
Failure to Assess Bed Rail Use Prior to Implementation
Penalty
Summary
A resident admitted with a diagnosis of cancer and on hospice services was observed to have bilateral half bed rails in place. The resident was cognitively intact and required extensive assistance for bed mobility, but stated that the rails were not used to turn. Review of the clinical record revealed there was no assessment conducted regarding the use of bed rails to determine if they posed a risk for entrapment or if they were necessary for the resident’s care. Interviews with staff confirmed that facility policy required an evaluation prior to implementing bed rails, including assessment of whether the rails functioned as a restraint, restricted movement, or posed an entrapment risk. Despite this, staff acknowledged that no such assessment was completed for this resident, even though there were orders for the rails. Maintenance staff were unaware of the rails being in place, and hospice staff confirmed that an assessment was not requested until after the rails had already been applied.
Failure to Provide Recommended Mental Health Services
Penalty
Summary
A resident with diagnoses of post-traumatic stress disorder, agoraphobia, and bipolar disorder was readmitted to the facility and exhibited ongoing depressive symptoms, irritability, and refusal of care, as documented in both the Minimum Data Set (MDS) assessment and physician progress notes. The physician recommended consideration of a referral for a geriatric psychiatric evaluation due to the resident's continued mental health symptoms. However, a review of the clinical record revealed that no referral for mental health evaluation was made, and there was no documentation of any behavioral health services being offered or provided to the resident. Staff interviews confirmed that the resident remained isolated in their room, often with the lights off, and frequently refused personal care. The Certified Nursing Assistant (CNA) described the resident as moody and irritable, with a pattern of refusing care. The Social Services Director was unaware of the physician's recommendation for behavioral health services and acknowledged that no referral had been documented or made. Facility leadership also confirmed that the resident did not receive a behavioral health evaluation, resulting in a failure to provide appropriate mental health services as recommended.
Failure to Appropriately Monitor and Administer Medications
Penalty
Summary
The facility failed to ensure appropriate monitoring and administration of medications for three residents. For one resident with a mental health disorder, a physician's order to decrease the dose of divalproex was not implemented for approximately a month, despite the order being documented in the medical record. This delay was confirmed by both the attending physician and the Director of Nursing Services (DNS). Another resident with Type II diabetes mellitus and neuropathy continued to receive tramadol for pain after a physician's order to discontinue the medication had been issued. Medication administration records showed multiple doses were given after the stop order, which was acknowledged by the DNS. A third resident with heart disease and chronic pain received metoprolol, an anti-hypertensive medication, even when their diastolic blood pressure was below the facility's standing order parameters. The standing orders required staff to hold anti-hypertensive medications if the diastolic blood pressure was below 60, but this was not followed. A certified medication aide (CMA) stated she was unaware of the standing orders and believed medications should only be held if specified on the medication administration record. The DNS confirmed that the medication should not have been administered under these circumstances.
Delayed Physician Notification of Lab Results for UTI
Penalty
Summary
The facility failed to promptly notify the ordering physician of laboratory results for a resident who was admitted with kidney failure and was being evaluated for a suspected urinary tract infection (UTI). Laboratory samples were collected, and while the initial urinalysis results were communicated to the physician, the final culture results were not reported until six days later. During this period, the resident was not started on antibiotic therapy, and staff did not monitor for complications. Interviews with staff confirmed that there was an expectation to follow up with physicians in a timely manner regarding lab results, and acknowledged that the delay in notification was not appropriate.
Missing Laboratory Results in Resident Record
Penalty
Summary
The facility failed to ensure that laboratory results were included in the clinical record for one resident who was admitted with a diagnosis of stroke. A prescriber ordered blood tests, including thyroid hormone levels, and staff collected and sent the blood samples to the lab. However, the results of the thyroid hormone test were not present in the resident's clinical record. A consultant pharmacist's review noted that the labs had been sent but the results were missing from the record, and staff were unable to provide a reason for the absence of the results or explain why there was no follow-up to ensure the results were obtained and filed.
Failure to Provide Requested and Ordered Menu Items to Residents
Penalty
Summary
The facility failed to ensure that residents' food preferences and menu selections were honored, resulting in two residents not receiving requested or ordered food items. One resident, admitted with anxiety and protein-calorie malnutrition, requested pizza, which was prepared and announced over the intercom, but the resident never received it. The agency CNA responsible was assisting another resident at the time and did not retrieve the pizza, and the dietary manager acknowledged that agency staff may not have been trained on the process for food requests. The resident later stated it was too late to receive the pizza. Another resident, admitted with diabetes and protein-calorie malnutrition, did not receive oatmeal that was listed on their breakfast food ticket. The resident confirmed the omission, and a staff member verified that oatmeal was not present on the tray. The dietary manager explained that oatmeal bowls are placed on food carts, and if they run out, staff are expected to obtain more from the kitchen. The resident stated it was too late to get the oatmeal after finishing breakfast. Facility leadership confirmed that residents should receive the items listed on their food tickets.
Failure to Discontinue Ineffective Prophylactic Antibiotic During UTI
Penalty
Summary
The facility failed to provide appropriate antibiotic stewardship for a resident with incomplete quadriplegia who had a history of urinary tract infections (UTIs) and was on daily prophylactic trimethoprim. Upon admission, the resident was self-catheterizing with staff assistance and continued on the prophylactic antibiotic. A urine culture later identified a UTI caused by an organism resistant to trimethoprim. Despite this, the resident continued to receive trimethoprim daily throughout the month, while also being prescribed a seven-day course of amoxicillin to treat the acute infection. Staff interviews confirmed that the prophylactic antibiotic was not discontinued after resistance was identified, and no documentation was provided to show that the resident's provider approved the continuation of trimethoprim. The Director of Nursing stated the antibiotic was continued to prevent other organisms, but the pharmacist indicated that the prophylactic antibiotic should have been held during the acute UTI unless a physician provided a specific rationale. This lack of action resulted in the continued use of an ineffective antibiotic without proper justification.
Failure to Maintain Cleanliness and Timely Repairs in Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and functional environment for two residents. One resident, admitted with heart disease, had a portable fan in their room with blades coated in a brown layer of dust. The Maintenance Director acknowledged the fan was dusty and was unsure who was responsible for cleaning the blades. The Housekeeping Manager stated that while the outside of fans were dusted daily, the blades were only cleaned when residents moved out of a room. Another resident, admitted with diabetes and a surgical site infection, experienced multiple issues with broken equipment in their room, including a non-functioning phone and room light. Work orders for these repairs were not completed in a timely manner, and staff were instructed to follow up on repair requests verbally. The resident's family was unable to reach them by phone and had to use 911 dispatch to make contact. An LPN reported needing to use a cell phone light to provide wound care due to the room light being out for three days. The facility administrator acknowledged that work orders were expected to be completed within 24 hours.
Failure to Provide Ordered Pressure Ulcer Treatment
Penalty
Summary
A resident with chronic pain and a Stage 3 pressure ulcer was admitted to the facility and had physician orders for wound care, including dressing changes and wound vac application three times per week. The care plan required staff to observe the wound dressing every shift and document wound observations during dressing changes. On a weekend, the resident did not receive the ordered wound treatment, and the wound vac was not changed as required. Staff interviews revealed that the wound treatment was missed due to an alleged lack of black foam needed for the wound vac, although the unit manager later confirmed that the black foam was in stock. There was no documentation or progress note related to the wound care for the missed treatment, and the physician was not informed about the missed wound care. This failure to follow physician orders placed the resident at risk for worsening of the pressure ulcer.
Failure to Provide Timely Insulin Administration Due to Delayed Pharmaceutical Services
Penalty
Summary
The facility failed to provide timely pharmaceutical services for a resident who was admitted with diagnoses including diabetes and a surgical site infection. Upon admission, the resident had hospital discharge orders for insulin to be administered three times daily with meals. However, documentation showed that the resident did not receive the prescribed lunchtime insulin dose on the day of admission, with the first insulin administration occurring later in the evening. Nursing notes indicated that the pharmacy received the prescription request after noon, and staff interviews confirmed that the resident's medications, including insulin, were not available upon arrival due to issues with the admission process and pharmacy delivery schedules. Further interviews with staff and the facility's pharmacist revealed that the pharmacy received the general medication order request after the deadline for immediate delivery, and an urgent request for insulin was not made until mid-afternoon, resulting in delivery several hours later. The Director of Nursing Services acknowledged that medications should be in place before a resident's arrival. This sequence of events led to a delay in the administration of essential insulin therapy as ordered for the resident.
Failure to Follow Infection Control Standards and Maintain Adequate Supplies
Penalty
Summary
The facility failed to adhere to infection control standards for contact and Enhanced Barrier Precautions for three residents. One resident with sepsis and a Foley catheter was placed on enhanced barrier precautions per physician order and care plan, but staff and family reported inconsistent use of gowns during catheter care. Staff confirmed that gowns were not consistently worn in precaution rooms prior to a certain date, despite expectations for immediate implementation of precautions. Another resident with diarrhea and a UTI was care planned for hand hygiene education and was on antibiotic prophylaxis. Multiple staff and the resident reported ongoing shortages of plastic bags, paper towels, and soap, which hindered the proper removal of soiled linens and appropriate hand hygiene. Staff described having to carry soiled items through hallways or dispose of them in unlined garbage cans, and confirmed that supply shortages were a recurring issue, sometimes related to housekeeping budget constraints and supply management practices. A third resident with a Stage 3 pressure ulcer and a positive wound culture was placed on contact precautions, with signage indicating the need for gowns and gloves. However, staff were observed entering the resident's room and handling personal items without donning the required personal protective equipment (PPE). Some staff stated they believed PPE was only necessary for direct contact, despite the posted precautions and infection preventionist's confirmation that PPE was required when within three feet of the resident or touching personal belongings.
Failure to Maintain Essential Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment, specifically the low temperature dish machine, which placed residents at risk for foodborne illnesses. The dish machine's wash cycle temperatures were required to remain between 120 to 140 degrees Fahrenheit, but logs indicated that the temperatures only reached 120 degrees on specific dates. A work order was submitted by the Dietary Manager due to insufficient hot water, marked as high priority, but was not addressed in a timely manner. The Regional Director of Maintenance marked the issue as completed, but the problem persisted, leading to the use of paper products for meal service when water temperatures were inadequate. Staff interviews revealed that the dish machine's water temperatures were inconsistent, with reports of cold water affecting both dishwashing and resident showers. Despite the inadequate temperatures, management instructed staff to continue using the dish machine, relying on chemical sanitizers. The Regional Dietary Manager acknowledged that the dish machine did not meet the expected wash cycle temperatures, and the Regional Director of Maintenance admitted that the priority work order was not processed promptly, although a new hot water heater was ordered.
Failure to Provide Properly Textured Diets
Penalty
Summary
The facility failed to provide modified textured diets as ordered for two residents, leading to potential risks for medical complications and aspiration. Resident 1, diagnosed with Alzheimer's disease and mood disturbance, required a pureed diet due to swallowing issues. However, on one occasion, a chunk of meat was found in the resident's pureed food, which was not completely processed. Staff 12, the cook, acknowledged the issue, and Staff 10, a CMA, reported the concern to the Dietary Manager. The Dietary Manager, Staff 4, was aware that the non-commercial food processor purchased was inadequate for ensuring a smooth consistency for pureed diets. Resident 2, with a history of stroke and heart disease, also required a pureed diet. The resident was observed with a plate of pureed food that contained small pieces of food, indicating it was not smooth in texture. Staff 4 admitted to not receiving official training related to diet textures, and Staff 9, an SLP, confirmed the food texture did not meet expectations. Staff 12 expressed concerns about the safety of the pureed food texture, and the Regional Dietary Manager, Staff 8, acknowledged the need for additional staff training.
Staffing Deficiency Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff to maintain the highest practicable physical and psychosocial well-being for residents, as evidenced by multiple observations and interviews. On one occasion, a resident was found with a soiled brief and expressed distress due to a lack of staff response to their call light. The staff member nearby was unable to assist immediately due to being behind schedule. Additionally, several other call lights were observed to be activated, indicating a delay in response to resident needs. Resident Council Notes from August to October 2024 highlighted ongoing concerns about long wait times for call lights, particularly on weekends, and staff expressing frustration about short staffing. Multiple residents and witnesses reported similar issues, with some residents experiencing delays of up to an hour for assistance. A family member also noted the difficulty in finding enough staff to assist with two-person tasks. The Director of Nursing Services acknowledged the staffing concerns, confirming the deficiency in meeting resident needs promptly.
Meals Served at Improper Temperatures
Penalty
Summary
Meals were not served at the proper temperature in the facility's kitchen, as observed during a survey. The Food and Drug Administration guidelines require eggs to be served at 135 degrees F or above and milk at 40 degrees F or below. However, during a breakfast test tray conducted with the Administrator and Dietary Manager, the eggs were found to be at 91 degrees F and the milk at 45 degrees F, both below the required temperatures. Residents expressed concerns about late meal service and cold food in the August and September 2024 Resident Council Notes. Multiple residents and a complainant reported that meals were often served late and cold, with one resident stating that meals were cold 75% of the time. Staff members, including dietary aides and a CNA, confirmed that food was consistently cold, lacked seasonings, and was often served late. The Dietary Manager verified that there was a delay between the meal cart being ready and the last resident tray being served.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, comfortable, and homelike environment for residents in two of the three rooms reviewed, specifically Rooms 117 and 118. Observations revealed that the walls underneath the windows in these rooms were in disrepair, and the baseboard coving was missing. This condition allowed outside air and odors, including cigarette smoke from a nearby outdoor smoking area, to enter the rooms. Witnesses, including a complainant and a resident, confirmed the presence of drafts and smoke odors, with staff resorting to placing towels around the affected areas to mitigate the issue. The facility's administrator and social service director acknowledged the problem, noting that maintenance was aware and that other rooms were similarly affected due to heater replacements.
Neglect of Resident Care Leading to Fall and Hospitalization
Penalty
Summary
The facility failed to ensure a resident's right to be free from neglect, which placed the resident at risk for unmet care needs. The resident, admitted with a left femur fracture, was to be assisted with toileting every two hours and required appropriate footwear for ambulation or transfers. On the day of the incident, the resident was found on the floor without socks or shoes and with a soiled brief, indicating neglect of care. The resident had not been assisted with toileting for several hours, and the call light was not on. Staff interviews revealed that the resident's bed linens were soaked with urine and feces, and the resident had not received incontinence care all morning. The facility's investigation confirmed neglect of care, as the resident had not been checked on as required. Staff members acknowledged the neglect, noting that the resident's condition was unusual and that the resident typically communicated the need for assistance. The investigation concluded that the resident may have attempted to use the bathroom independently, leading to the fall. The resident was later diagnosed with a urinary tract infection at the hospital, although no injuries from the fall were reported.
Failure to Provide RN Coverage for Required Hours
Penalty
Summary
The facility failed to staff a registered nurse (RN) for eight consecutive hours per day, seven days a week, for 22 out of 91 days reviewed. This deficiency was identified through interviews and record reviews, including the facility's Direct Care Staff Daily Reports and payroll documents. The specific days without adequate RN coverage were noted in January, February, and March 2024. On June 17, 2024, during an interview, the Administrator and the Director of Nursing Services (DNS) acknowledged the lack of RN coverage on the specified days. The Administrator stated that she expected RN coverage for eight hours each day, but this expectation was not met, placing residents at risk for unmet assessment needs.
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 105 citations issued within 25 miles in the last 12 months — 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 Corvallis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Timberline Post Acute | 6.8 mi | ★★★★★ | 8 | 0 |
| Regency Albany | 7.1 mi | ★★★★★ | 14 | 0 |
| Mennonite Home | 8.4 mi | ★★★★★ | 8 | 0 |
| Avamere Rehabilitation Of Lebanon | 16.7 mi | ★★★★★ | 28 | 0 |
| Lebanon Veterans Home | 17 mi | ★★★★★ | 17 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 August 2026) and official state health department websites.