Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Green Valley Rehabilitation Health Center during CMS and state inspections, most recent first.
Failure to assess residents for self-administration of medications: Several residents had meds or OTC products at bedside or in their rooms, including topical creams, inhalers, and antiseptic spray, without a completed self-medication assessment for the specific items. Staff reported that evaluations and orders were expected before bedside storage or self-administration, but records showed missing assessments and, in some cases, staff were unaware the items were present or which meds were approved.
A facility failed to keep meals palatable and at a safe, appetizing temperature. Residents with conditions including anemia, kidney failure, heart disease, muscle wasting, and diabetes reported that breakfast and lunch trays were often cold, late, or missing items, and staff observed trays delivered to rooms without warming plates. CNAs and management acknowledged frequent complaints about cold food, delays in meal delivery, and food running out.
A resident with diagnoses including a femur fracture and visual hallucinations was prescribed risperidone for dementia with behaviors and trazodone for insomnia. Consent was documented for risperidone, but no consent was found for trazodone, and the MAR showed both meds were being given. The DNS acknowledged the resident was not informed of the risks and benefits of either psychotropic medication before use.
Advance Directive Rights Not Properly Addressed: The facility failed to consistently discuss, document, and obtain copies of advance directives for multiple residents. One resident with moderate cognitive impairment said staff never reviewed the details of an existing advance directive and the copy was missing from the chart, another resident had a signed advance directive but the care plan was inaccurate and no copy was on file, and a cognitively intact resident said staff never explained what an advance directive was and there was no documentation of education or offer of assistance.
Unsecured computer screens on a treatment cart and a med cart exposed resident health information for two residents. Staff left the carts unattended with the screens unlocked, allowing a resident's code status, allergies, care information, and another resident's med list to remain visible. An LPN and the DNS stated the screens should be locked when not in use.
A resident with chronic lung disease and intact cognition reported that the toilet made a very loud noise when flushed at night and scared him/her. A CNA stated the toilet had been loud for about two months and that maintenance was notified through an online system when equipment needed repair, but maintenance said he had not been notified. When maintenance flushed the toilet, it made a loud foghorn-like noise.
A resident admitted with alcohol abuse and encephalopathy was identified as at risk for isolation, depression, and further decline, but the revised care plan did not address the resident’s preferences, likes, dislikes, or activities to avoid isolation. The resident said he/she was not aware of any facility activities and wanted to participate, was observed alone in the hallway and eating lunch alone, and staff reported uncertainty about participation; the Activities Director acknowledged the care plan was not comprehensive.
Care plans were not kept current and IDT care conferences were incomplete for multiple residents. One resident with heart disease was observed without a bed despite a care plan listing bed canes, another resident with heart failure and diabetes had care conferences attended only by an ASW with no nursing issues documented or resident concerns addressed, and a third resident with kidney disease had dental status and denture needs that were not reflected in the care plan.
Restorative services were stopped for a resident with limited mobility after a joint replacement, even though the care plan included a nursing restorative program with walking. The resident said exercises had been provided and then suddenly stopped, but the record had no documentation showing current restorative services or a rationale for discontinuation. The DOR, Restorative Aide, RNCM, and DNS all confirmed the resident was removed from services and that no assessment or documented reason for stopping the program was present.
A resident who was cognitively intact and dependent on staff for personal hygiene was not consistently provided hygiene assistance, including shaving, despite stating a preference to be clean shaven. Shower records showed multiple refusals, only two showers in 30 days, and several refusals without documentation that the nurse communicated with the resident or explored the reason for refusal. Staff stated residents were usually shaved on shower days, and the care plan did not address the resident’s shaving preference.
Failure to provide meaningful activities for a resident with dementia, seizures, and anxiety. The resident’s MDS noted interest in religious activities, outdoor time, and group activities, but the care plan lacked activity preference details and the activity log showed no activities were offered over the prior 30 days. The resident was observed alone in the room and said no staff had asked about activity preferences, while staff reported limited follow-up, incomplete activity care planning, and training gaps.
A resident with paraplegia and intact cognition was found keeping cigarettes and a lighter in a personal bag instead of having smoking paraphernalia stored at the nurse's station as directed in the care plan. The same resident had repeated falls from a power wheelchair after unbuckling the seatbelt and sustained serious injuries, but OT and PT evaluations after the falls did not assess the wheelchair for possible safety adaptations.
A resident with severe osteoarthritis and chronic pain had persistent pain scores mostly in the 6-10 range over many months despite orders for Tylenol, Lyrica, lidocaine patches, and cyclobenzaprine. The resident reported severe, unrelieved pain that interfered with sleep, activity, and therapy, and staff described frequent crying, grimacing, and staying in the room because of pain. The PA noted the resident was not a surgical candidate, the SSW had not arranged a pain clinic appointment, and the UM said staff had not told her the regimen was ineffective or interviewed the resident about pain.
Incomplete assessment of PTSD-related triggers: A resident with insomnia, post-traumatic seizures, anxiety, and a BIMS of 15 was noted to be sensitive to loud noises from military service, but the care plan did not include PTSD triggers. The resident later reported needing a specific sleep environment, including sound in the room, the TV on, and drapes tucked against the window to feel safe. A CNA knew the resident was afraid of the dark and needed the shades closed, while an Activity Assistant did not report concerns to nursing and the DOSS acknowledged the resident lacked a thorough assessment and related care plan interventions.
Failure to provide dental services for a resident who had no teeth and requested implants. The resident had diabetes and mild cognitive impairment, and the record noted a need for dental evaluation, but no dental referrals were found. The resident stated no one had discussed dental services for a long time, and an RNCM confirmed the resident could be transported to dental appointments.
Missing Consent for Influenza Vaccinations: Two cognitively intact residents received influenza vaccines without signed consent forms in their records. One resident had a hx of stroke with left-sided paralysis and DM, and the other had ESRD with left-sided paralysis following a stroke. RN/IP verified the missing consents, and the DNS stated she expected nursing staff to obtain signed consent before giving any vaccinations.
Missing consent documentation for COVID-19 vaccinations: The facility administered COVID-19 vaccines to two cognitively intact residents without signed consent forms in the medical record. One resident had a hx of stroke with left-sided paralysis and DM, and the other had ESRD with left-sided paralysis following a stroke. The RN/IP verified both residents lacked documented consent, and the DNS stated she expected nursing staff to obtain a signed consent before giving any vaccination.
The facility did not maintain required RN coverage for at least eight consecutive hours per day on multiple days, as shown by review of Direct Care Staff Daily Reports over several months. Staff reported that the RN manager was only recently added to the staffing report, and the Administrator stated that staff were expected to call off two hours before their shift to allow time to find coverage. When surveyors requested payroll records to verify RN presence on the identified days, no additional documentation was provided, resulting in a cited deficiency for inadequate RN staffing.
A resident with depression and intact cognition reported missing jewelry, an oximeter, and art supplies to staff and during a resident council meeting, where residents had raised concerns about missing items. A CNA stated the resident had reported missing earrings and an oximeter and that she informed the charge nurse, but did not assist with another grievance form because the resident had already completed one. The facility’s grievance log showed no entry for this resident, and the Director of Social Services and Recreation could not locate or recall any grievance related to the missing items, suggesting it may have been lost amid staff confusion. The Administrator stated he would have expected staff to complete and resolve such a grievance within five days, but this did not occur, indicating the grievance process was not followed or tracked as required.
The facility failed to report an incident of potential neglect involving an elopement to the State Survey Agency. A resident with anxiety and a cognitive communication deficit was found off premises near a busy street after their wander guard device was not functioning. An internal elopement investigation identified confusion and device failure as the root causes, but no Facility Reported Incident (FRI) was submitted. The former administrator reported she would not report an elopement because it was no longer on the FRI form, and the current administrator confirmed that no FRI was completed, despite the regional RN’s expectation that an FRI be submitted for such an alleged violation.
A resident with severe cognitive impairment and a history of wandering had a care plan and TAR requiring a Wander Guard on the wheelchair and shift-by-shift checks of its placement and function, along with diversional interventions. Surveyors found no documentation that staff performed these required Wander Guard checks. The resident subsequently eloped and was found confused and in a precarious position near a busy street, and staff reported the resident did not have a Wander Guard on the wheelchair at that time. Although 15-minute checks were ordered after the elopement, there was no documentation that these monitoring checks were completed, and the administrator confirmed that no monitoring sheets could be located.
A resident who required moderate assistance for transfers and was cognitively intact reported being told by a speech therapist to urinate in bed if staff were unavailable to help with toileting, rather than attempting to transfer alone. The resident felt degraded by this comment, and the speech therapist confirmed she would give such instructions to prevent unsafe transfers.
A resident with a hip fracture and chronic pain did not receive prescribed pain medications on multiple occasions due to pharmacy and reordering issues, resulting in unmanaged pain. After a change in wound care orders, staff failed to monitor the surgical wound, leading to infection and hospitalization. Staff interviews confirmed lapses in medication administration and wound monitoring.
The facility failed to provide adequate staffing, resulting in delayed care, missed showers, and late meals. Residents experienced long call light wait times, were left in soiled briefs, and received late meal trays. Staff reported being unable to complete care tasks due to high resident acuity and insufficient staffing levels.
A facility failed to adhere to physician's orders for a resident with respiratory failure and asthma, leading to the resident attending an appointment without necessary oxygen support. The resident was later observed receiving oxygen at four liters per minute without a documented order, highlighting a lapse in following prescribed respiratory care protocols.
A resident with a stroke and moderate decision-making impairment was injured when a CNA, frustrated by a reassignment, pushed the resident's shower chair, causing a toe injury. The CNA left the resident alone without a call light and did not report the incident, leading to the resident's mistreatment and injury.
A facility failed to supervise a resident with dysphagia during meals, leading to unsupervised eating. Another resident with dementia and a history of elopement left the facility unsupervised and was missing for nearly 24 hours. Additionally, a resident with a history of falls fell from an elevated bed, resulting in leg fractures, due to inadequate adherence to safety protocols.
A resident reported being served moldy food, prompting an investigation that revealed unsanitary conditions and improper food storage in the facility. The dietary service logs showed inadequate food temperatures, and the unit refrigerator was found with unlabeled sandwiches, a broken shelf, and a sticky, uncleanable wooden shelf. Despite some labeling improvements, the unsanitary conditions persisted.
The facility failed to obtain informed consent for psychotropic medications for four residents. A resident with a pulmonary embolism was prescribed sertraline and lorazepam without consent. Another resident with bipolar disorder received duloxetine without being informed of the risks and benefits. A third resident, readmitted for leg fracture repair, was prescribed haloperidol and Ativan without consent. Lastly, a resident admitted after a stroke was given Lexapro without consent. Staff acknowledged the oversight in obtaining informed consent.
The facility failed to address grievances raised by the Resident Council, leading to a deficiency. Despite a grievance policy requiring immediate action, issues such as poor CNA performance, delayed meals, and mishandling of personal items were not resolved. Frequent changes in administration and unclear grievance handling responsibilities contributed to the problem, with no follow-up or resolutions documented.
The facility failed to ensure the Activities Director was a qualified professional. The Activities Director, promoted in July 2024, lacked the necessary certification, which was confirmed by the Administrator. This placed residents at risk for unmet physical, mental, and psychosocial needs.
The facility failed to ensure that three residents understood the arbitration agreement they signed. Despite being cognitively intact, the residents and their representatives reported a lack of understanding and felt uninformed about the arbitration process. The Admissions Coordinator claimed to explain the process and provide contact information for questions, but the residents' feedback indicated a communication failure.
The facility failed to maintain proper infection control practices, including improper use of PPE, unsanitized medical equipment, and deficiencies in the laundry area. Staff were observed not wearing masks in COVID-19 areas, and a glucometer was not sanitized between uses, risking infection spread. Equipment issues in the laundry room further compromised infection control.
The facility failed to ensure a clean and homelike environment for residents, with issues such as cluttered rooms, unclean bathrooms, unpainted wall patches, and broken window blinds. Staff acknowledged these deficiencies, indicating a lack of effective communication and maintenance reporting.
The facility failed to document and resolve grievances for three residents and one unit, leading to unresolved concerns about missing personal items, rude staff interactions, moldy food, and inadequate incontinence care. Despite residents being cognitively intact and reporting issues, grievances were not properly recorded or communicated, indicating a systemic failure in handling grievances.
The facility experienced significant staffing shortages, resulting in delayed care for residents. Multiple complaints and observations highlighted long call light wait times and unmet care needs, such as incontinence care and meal assistance. A resident with heart disease frequently waited for bowel and bladder care, causing frustration and stress. Staff confirmed the facility was consistently short-staffed, with high turnover and frequent call-offs exacerbating the issue.
The facility did not staff an RN for eight consecutive hours per day for seven days out of 93 reviewed, risking unmet assessment needs. This was identified through staff daily reports from April to September 2024. The administrator, DNS, and regional nurse acknowledged the issue but provided no further information.
The facility failed to post accurate staffing information for six consecutive days, omitting census documentation for various shifts. This placed residents at risk for incomplete staffing information. The Administrator, DNS, and Regional Nurse acknowledged the requirement for staff to document the census for each shift.
A facility failed to ensure a safe system for a resident's self-administration of medication, leading to an adverse reaction. A resident, admitted with heart disease and cognitively intact, was assessed to self-administer medications, but the specific medications were not identified. The resident mistakenly applied Desitin to a skin graft site, worsening its condition. Observations showed unsecured medications in the resident's room, contrary to facility policy. Staff acknowledged the oversight, highlighting a failure in medication management.
A resident with chronic kidney disease expressed a desire to formulate an advance directive with a friend's help. Despite this being noted during a care plan conference, there was no documented follow-up or communication from staff to assist the resident in this process. A social services staff member confirmed the request but lacked documentation of any assistance provided.
A resident with a stroke diagnosis suffered a toe injury when a CNA, frustrated by a reassignment, pushed the resident's shower chair, causing the toe to hit a door. The CNA left the resident alone without a call light and did not report the incident. The facility's investigation lacked interviews with involved parties.
The facility failed to notify the State Long-Term Care Ombudsman of hospitalizations for two residents, one with cancer and another with anxiety and a leg fracture. Both residents were transferred to the hospital without the required notifications, leaving them without access to an advocate. Staff interviews confirmed that medical records staff did not complete the necessary notifications.
The facility failed to provide a bed hold policy to two residents transferred to the hospital, risking their knowledge of the right to return. One resident with cancer and another with anxiety and a leg fracture were not given the policy, and staff were unsure of the procedure. The absence of documentation was confirmed by the facility's administration.
The facility failed to update care plans for three residents, leading to potential unmet needs. A resident with chronic pain had undocumented personal equipment, another with depression and paraplegia lacked specific anxiety interventions and personal care preferences, and a third resident's care plan did not include interventions for psychotropic medications. Staff acknowledged these oversights.
Two residents in the facility experienced a lack of meaningful activities, leading to potential isolation. One resident with dementia and depression was often bored and unable to go outside due to the discontinuation of their electric wheelchair. Another resident with depression and anxiety reported that staff did not inquire about their interest in activities like crocheting. Staffing challenges in the activities department and the absence of activities staff at care conferences contributed to these deficiencies.
A resident with depression and paraplegia required hearing services, specifically ear cleaning, as identified in a care plan conference. Despite this, staff acknowledged ongoing hearing issues and ear wax build-up, which were not addressed due to the Unit Manager's failure to obtain necessary physician orders.
A resident at risk for pressure ulcers developed a Stage 3 ulcer that was not assessed or treated in a timely manner. Despite being reported by a CNA, the ulcer was not comprehensively assessed until three days later, and treatment was delayed. The LPN did not stage the ulcer, citing scope of practice limitations, and the presence of an RN in the facility did not lead to timely intervention.
The facility failed to provide adequate respiratory care for three residents. A resident with chronic pain had an unused, dusty suction machine in their room, contrary to physician orders. Another resident with a pulmonary embolism did not receive documented oxygen therapy, and staff were unclear about the orders. A third resident with respiratory failure had a nebulizer improperly stored and without cleaning instructions. These deficiencies indicate a lack of adherence to physician orders and standards of practice.
A resident with a leg fracture and pain from orthopedic devices did not receive PRN pain medication as ordered, despite frequent requests. The resident, cognitively intact, reported activating the call light for pain relief, but staff did not respond promptly due to low staffing and high workload. The facility acknowledged the expectation to administer pain medications as ordered.
A facility failed to provide appropriate post-dialysis care for a resident with end-stage renal disease. The resident's care plan required monitoring for infection, bleeding, and symptoms of kidney malfunction, as well as checking the thrill and bruit of the fistula. However, these checks were not consistently documented, and the order for checking the thrill and bruit was discontinued. Staff acknowledged missing documentation and poor communication with the dialysis center.
Failure to assess residents for self-administration of medications
Penalty
Summary
The facility failed to determine whether residents were clinically appropriate to self-administer medications for 4 of 9 sampled residents. The report states that residents had medications or topical products at the bedside or in their rooms without a completed self-administration assessment and, in some cases, without staff awareness of the items being present. Facility staff and leadership stated they expected an evaluation and orders to be in place before residents were allowed to keep medications at bedside or self-administer them. Resident 5 was admitted with heart failure and had a self-administration form from 3/11/24 stating the resident was capable but did not want to self-administer medications. The resident had an order for Salonpas PRN left knee pain that could be kept at bedside, but the clinical record did not show an assessment to ensure the resident was safe to administer the medication. The resident’s quarterly MDS later showed moderate cognitive and memory problems. Staff stated that a resident needed an assessment before medications could be kept at bedside and that Resident 5 had not been assessed for self-administration. Resident 10 had diagnoses including calcific tendinitis of the left shoulder and pneumonia, and the quarterly MDS showed a BIMS score of 12 with moderate cognitive impairment. Observations showed lidocaine cream and 3% hydrogen peroxide antiseptic spray in the resident’s room, and the resident demonstrated using both products. The record did not show a self-administration assessment for the topical lidocaine or antiseptic spray. Resident 12 was cognitively intact and had Breyna and albuterol inhalers at bedside, with the MAR showing provider approval to keep them there, but the record included a self-administration assessment for a different resident and did not show an assessment for the specific inhalers or storage location. Staff gave conflicting statements about which inhalers were present and whether a lockbox existed. Resident 68 had Alzheimer’s disease and a BIMS score of 8, indicating moderate cognitive impairment. Ammonium Lactate cream was observed by the bedside and on the shelf, with the resident stating staff did not assist with application and that the cream was for gangrene on the feet. The record did not show a self-administration assessment for the cream, and staff stated they were not aware the resident had medications at bedside. Resident 108 had muscle weakness and chronic pain, with a BIMS score of 15. Antifungal powder, Aspercreme, and Icy Hot were observed in the room, and the resident stated the products were sometimes used on self. The record did not show a self-administration assessment for these products, and staff stated the resident and family were known to bring OTC medications into the room without an order for self-administration.
Cold and Unappetizing Meals Served to Residents
Penalty
Summary
The facility failed to ensure food temperatures were maintained and to provide palatable food for residents receiving meals from the kitchen. Resident 11, admitted with anemia and kidney failure and assessed with a BIMS score of 15, stated on multiple occasions that breakfast items such as eggs, toast, and oatmeal were cold and that meals were often cold. On observation, Resident 11 was seen with a breakfast tray in the room and said the food was not warm and refused to eat it, while staff did not offer to address the cold food. Staff also acknowledged that residents frequently complained about cold food and that it was difficult to warm all trays while completing other duties. Resident 29, admitted with heart disease and requiring staff assistance with meal set-up, was observed with a meal tray in the room and stated the food was not warm. The resident later reported meals were often late and cold, and that reheated food took too long to be returned. Resident 57, who had muscle wasting and diabetes and was on a controlled carbohydrate regular texture diet, received a lunch tray without a warming plate and stated the pork chop did not feel warm and food was often served cold. Staff later stated missing items had run out, and staff and management acknowledged complaints about cold food and food running out on Sequoia Hall.
Failure to Inform Resident of Psychotropic Medication Risks and Benefits
Penalty
Summary
The facility failed to ensure a resident was informed of the risks and benefits of psychotropic medications before use. Resident 13 was admitted with diagnoses including right femur fracture and visual hallucinations, and physician orders in 1/2026 showed risperidone ordered for dementia with behaviors and trazodone ordered for insomnia. The resident had verbal consent documented for risperidone, but no consent was found for trazodone. A review of the 1/2026 MAR showed the resident received risperidone twice daily and trazodone each evening. On 1/30/26, the DNS acknowledged that Resident 13 was not informed of the risks and benefits of risperidone and trazodone prior to use.
Advance Directive Rights Not Properly Addressed
Penalty
Summary
The facility failed to have a process in place to ensure resident rights related to advance directives for 3 of 4 sampled residents reviewed. The facility’s policy stated that if a resident had not formulated an advance directive, staff would determine whether the resident wished to do so, offer assistance in accordance with state law, document the discussion and the resident’s acceptance or declination, and periodically review advance directives with the resident and/or representative. Resident 10, admitted with diagnoses including calcific tendinitis of the left shoulder and pneumonia, had a quarterly MDS showing a BIMS score of 12, indicating moderate cognitive impairment. The resident stated having an advance directive, but staff did not discuss the details with the resident, the copy was not on file, and there were no subsequent notes showing attempts to obtain it. Resident 30 had a signed Advance Directive Resident Information form, but the care plan stated the resident did not have an advance directive and no copy was on file; staff acknowledged the care plan was not updated and the copy was not obtained within a week as expected. Resident 108, admitted with diagnoses including muscle weakness and chronic pain, had a quarterly MDS BIMS score of 15 and stated the facility had not talked to the resident about an advance directive and the resident did not know what one was; staff confirmed there was no advance directive, no education, and no notes showing the resident was educated or offered one.
Unsecured Computer Screens Exposed Resident Health Information
Penalty
Summary
The facility failed to keep residents' health information private and confidential for 2 of 2 sampled residents, Resident 82 and Resident 105. On 1/26/26 at 10:44 AM, a treatment cart was observed with a computer screen unlocked, and Resident 82's information was visible, including code status, allergies, and care to be provided, while staff were not at the cart. On 1/26/26 at 4:10 PM, a medication cart computer screen was observed with Resident 105's medication list visible, and staff were not within sight of the cart. Staff 16, a CMA, stated the computer screen was to be locked when not in use and said he was called away from the computer and did not lock the screen before leaving the cart. Staff 7, an LPN, stated the computer screen should be locked, and Staff 2, the DNS, stated staff were to lock the computer screens before leaving the cart.
Delayed Repair of Loud Resident Toilet
Penalty
Summary
The facility failed to ensure a resident's toilet was repaired in a timely manner. Resident 115 was admitted in 3/2025 with chronic lung disease, and the Significant Change MDS indicated the resident was cognitively intact. On 1/26/26, the resident stated that when the toilet flushed at night it made a really loud noise and scared him/her. On 1/28/26, a CNA stated the toilet had been very loud when flushed for approximately two months and that maintenance was notified through an online communication system when equipment needed repair. Later that day, maintenance staff flushed the toilet and heard a loud foghorn-like noise. The maintenance staff stated he was not aware and had not been notified by staff that the toilet was loud when flushed.
Incomplete Activity Care Plan and Resident Isolation
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for 1 of 3 sampled residents reviewed for activities, Resident 92. Resident 92 was admitted in 12/2025 with diagnoses including alcohol abuse and encephalopathy. The 12/16/25 admission MDS indicated the resident was at risk for isolation, depression, and further decline, and stated the resident would be referred to activities to avoid isolation. However, the 1/11/26 revised care plan did not address the resident’s preferences, likes, dislikes, or activities to avoid isolation. During the survey, Resident 92 stated on 1/26/26 that he/she was not aware of any activities in the facility and would like to participate. The resident was observed sitting alone in the hallway on 1/28/26, eating lunch alone in the room on 1/29/26, and during random observations from 1/29/26 through 2/2/26 was seen sitting in the room or walking the halls alone on day and evening shifts. Staff 39, a CNA, stated the resident did not participate in the facility but had mentioned wanting to try music exercise, though the CNA did not know if the resident actually went. Staff 42, an LPN, stated she was not aware if the resident participated in activities but knew the resident walked around the facility. Staff 23, the Activities Director, acknowledged the care plan was not comprehensive, and Staff 2, the DNS, stated the expectation was for RCMs and staff to work together to provide resident preferences and activities and have a comprehensive care plan reflecting those preferences.
Care Plans Not Updated and IDT Conferences Incomplete
Penalty
Summary
The facility failed to ensure appropriate interdisciplinary team members were present for resident care conferences, failed to ensure care plans were updated to reflect current status, and failed to hold care planning meetings for 3 of 6 sampled residents reviewed for dentures and care planning. Resident 5 was admitted with heart disease and had a care plan updated on 9/19/25 that identified risk for ADL self-care and included bilateral bed canes for mobility, but on 1/27/26 the resident was observed sitting in a recliner and did not have a bed in the room. Staff later stated the resident had not had a bed for a while and the care plan had not been updated to reflect the change. Resident 30 was admitted with heart failure and diabetes, and the IDT care plan conference evaluations showed only an assistant social worker present, with no additional staff documented and no nursing subject matter discussed. The resident had a BIMS score of 12 on the 1/7/26 quarterly MDS, and a 1/10/26 Hgb A1c clinical report showed diabetes was well controlled. The resident stated concerns about heart medication changes and wanting a Hgb A1c were not addressed, could not recall any IDT meetings with a nurse present, and was not aware of Hgb A1c results. Resident 71 was admitted with kidney disease, stated she did not have dentures, and was observed without teeth; however, the care plan revised on 10/14/25 stated the resident did not have teeth and staff were to assist with denture care, while staff later stated they had never seen the dentures and the RNCM was not aware the resident did not have dentures or that the care plan did not reflect current dental status needs.
Restorative Program Discontinued Without Documentation
Penalty
Summary
The facility failed to provide a restorative program for Resident 55, who was admitted in 9/2024 after a joint replacement and whose care plan revised on 9/26/25 identified limited mobility with a nursing restorative program that included walking. The resident’s 12/22/25 quarterly MDS showed cognitive intactness. On 1/26/26, the resident stated that exercises had been provided and then suddenly stopped. The clinical record did not contain documentation showing that the resident was currently receiving restorative services or a rationale for discontinuation. Staff 5, the Director of Rehabilitation, stated on 1/29/26 that the resident was not on the current restorative list. Staff 33, the Restorative Aide, stated the resident had a respiratory illness and restorative was discontinued, and said she informed the RNCM. Staff 3, the RNCM, stated the resident had a respiratory illness and staff removed the resident from services, and also stated there should be a note documenting the rationale for discontinuation; Staff 3 stated there was no assessment or rationale for stopping the restorative program. Staff 2, the DNS, stated that after therapy develops a restorative program, it is nursing driven and the RNCM should be involved in decisions to discontinue the program.
Failure to Provide Personal Hygiene Assistance
Penalty
Summary
The facility failed to ensure personal hygiene was provided for 1 of 4 sampled residents reviewed for ADLs. Resident 55 was admitted with a diagnosis of joint replacement, was cognitively intact on the 12/22/25 Quarterly MDS, and the care plan revised on 9/26/25 identified an ADL self-care performance deficit with an intervention that the resident was dependent on staff for personal hygiene. On 1/26/26, the resident stated a need for assistance to shave and a preference to be clean shaven, but was observed in bed and not shaved, with facial hair approximately 0.25 inches long. An undated shower schedule showed the resident was scheduled for Tuesday and Thursday mornings. Shower documentation and progress notes from 12/31/25 through 1/21/26 showed multiple refusals and limited showers, with only two showers documented in 30 days. Several refusals had no progress note showing nursing communication with the resident. Staff stated that if a resident refused a shower, the resident was to be offered assistance two more times that day, then the nurse was to be notified and communicate with the resident; staff also stated residents were usually shaved on shower days. The RNCM stated the resident often refused showers and shower days were changed, and acknowledged the care plan did not address the resident's shaving preference. The DNS stated shower and shaving preferences were to be determined upon admission and that refusal reasons should be found out and documented, but she did not see documentation for shower refusals.
Failure to Provide Meaningful Activities Based on Resident Preferences
Penalty
Summary
The facility failed to provide meaningful activities for a dependent resident, identified in the report as Resident 61, who was admitted with diagnoses including dementia, post-traumatic seizures, and anxiety. The 11/11/25 admission MDS indicated a BIMS score of 15 and noted the resident was unable to complete the interview for Preferences for Routine and Activities. The MDS also indicated staff knew it was important for the resident to participate in religious activities, spend time outdoors, and do things with groups of people. A 11/14/25 care plan directed staff to invite the resident to leisure programs, but no information about the resident’s activity preferences was identified in the care plan. The 12/28/25 through 1/27/26 Task: Activity Involvement document showed the resident was not offered activities during the last 30 days. On 1/27/26, the resident was observed sitting alone on the bed in the room and stated no staff had interviewed him/her regarding activity preferences, though the resident was interested in bingo. Staff 21 stated no information about the resident’s activity preferences was in the care plan and that the resident liked to stay secluded in the room. Staff 24 stated she offered books to residents on the skilled wing and moved on when residents declined books or room activities. Staff 23 stated she interviewed the resident about activity preferences, but did not complete activity care plans and was aware she did not correctly complete the admission MDS due to lack of training; she also acknowledged follow-up with the resident for activities did not occur. The Administrator stated training was needed for activity staff and expected correct information about the resident’s activities and preferences in the MDS, care plan, and activities offered based on those preferences.
Smoking paraphernalia not secured and post-fall wheelchair safety not fully evaluated
Penalty
Summary
The facility failed to ensure a resident's smoking paraphernalia was stored securely. Resident 71 was admitted with paraplegia and was cognitively intact on the 1/2/26 BIMS. The resident's care plan identified the resident as an independent smoker and directed that cigarettes and lighters be stored at the nurse's station. However, during observation in the smoking area, the resident had a black bag in the lap containing a pack of cigarettes and a lighter. Staff stated the resident smoked in the morning with other residents, was allowed to smoke without supervision, and kept the lighter in the black bag. The RNCM stated she/he was not aware the resident kept the lighter and cigarettes in the bag, and the Administrator stated residents were to be monitored when they smoked and that the designated smoking area had locked boxes for storing smoking paraphernalia. The facility also failed to ensure the resident was evaluated for safety after falls. Resident 71's power wheelchair or scooter safety skills assessment indicated the resident was safe to use a power wheelchair. The resident's unwitnessed fall investigation showed the resident fell while in the power wheelchair after unbuckling the seatbelt and sustained a brain bleed. The investigation noted OT was to evaluate the resident in the chair to determine whether a different chair or adjustments to the current chair were appropriate for safety. The OT evaluation after the fall focused on sitting at the edge of the bed and did not include an evaluation of the wheelchair for safety adaptations, and continued OT services were not indicated. The PT evaluation also noted the resident had fallen twice after unbuckling the seatbelt and had serious injuries, but it did not include an assessment of whether additional adaptations could be made to the power wheelchair for safety.
Failure to Effectively Manage Chronic Pain
Penalty
Summary
The facility failed to effectively manage the pain of a resident with severe osteoarthritis and chronic pain. The resident, who was cognitively intact, had pain monitoring documented over the prior 12 months showing pain levels commonly ranging from 6 to 10 on a 1-10 scale on most days each month. The resident’s record included orders for Tylenol, Lyrica, lidocaine patches, and cyclobenzaprine for pain, and a pain assessment completed by an LPN documented severe pain that interfered with sleep, activity, and participation in therapy, with the resident stating an acceptable pain level would be 5. The resident reported chronic, unrelieved pain and stated movement usually worsened it, leaving the resident to lie completely still. The resident also stated opioid pain medication had been stopped after using a marijuana gummy because nothing else was working. Staff observed and described the resident as frequently crying, grimacing, and rarely leaving the room because of pain. A PA stated the resident had severe osteoarthritis and a hernia and was not a candidate for surgery due to weight, while the Social Services Director stated the last interdisciplinary team conference was in 2/2025 and no pain clinic appointment had been arranged. The Unit Manager stated staff had not informed her that the pain regimen was ineffective and she had not interviewed the resident about pain, and the DNS stated the facility had an obligation to oversee and collaborate on the effectiveness of resident care.
Incomplete assessment of PTSD-related triggers
Penalty
Summary
The facility failed to thoroughly assess a resident with trauma-related needs for 1 of 2 sampled residents reviewed for behaviors. Resident 61 was admitted with diagnoses including insomnia, post-traumatic seizures, and anxiety, and the admission MDS indicated a BIMS score of 15. The 11/11/25 ACTs My Way assessment noted the resident was sensitive to loud noises due to military service, and Staff 23, an Activity Assistant, conducted the interview. However, the 11/14/25 care plan contained no information about the resident’s PTSD triggers. During the 1/2026 monitoring period, Resident 61 slept from two to 11 hours per day. On 1/27/26, the resident stated having PTSD and reported that no one was aware of the need for a particular environment to sleep well, including having sound in the room with the television on and the drapes tucked against the window so no one could look in from outside. The resident stated this information was helpful for staff to know in order to feel safe. Staff 20, a CNA, stated she was aware the resident was afraid of the dark, needed the shades closed, and had reported the issue to nursing. Staff 23 acknowledged the resident was uneasy during the PTSD interview but did not report concerns to nursing and was unsure how the information was communicated to CNAs. Staff 9, the Director of Social Services, stated he expected staff communication when the resident indicated PTSD triggers and acknowledged the resident lacked a thorough assessment and needed interventions in the care plan to ensure the resident felt safe.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide dental services for 1 of 3 sampled residents reviewed for dental care. Resident 5 was admitted in 3/2024 with a diagnosis of diabetes, and a 3/19/25 health care provider summary noted the resident had been seen for chronic conditions and dental status, with a request to see a dentist for possible implants. A 1/20/26 NP wound note documented mild cognitive impairment, and the 1/27/26 care plan stated the resident did not have teeth and staff were to refer the resident to a dentist for evaluations. During interview on 1/26/26, Resident 5 stated he/she did not have teeth, wanted implants, and had not been spoken to about dental services for a long time. On 1/29/26, Staff 3 stated the resident was able to be transported to dental appointments, but no dental referrals were found in the clinical record.
Missing Consent for Influenza Vaccinations
Penalty
Summary
The facility failed to ensure consents were obtained before administering influenza vaccines to 2 of 5 sampled residents reviewed for vaccinations. Resident 9 was admitted in 1/2023 with diagnoses including paralysis of the left side following a stroke and diabetes, and a 10/23/25 quarterly MDS indicated the resident was cognitively intact. The medical record showed Resident 9 received an influenza vaccine on 10/2/25, but no consent for the vaccine was found in the record. Resident 62 was admitted in 6/2024 with diagnoses including end stage renal disease and paralysis of the left side following a stroke, and a 12/21/25 quarterly MDS indicated the resident was cognitively intact. The medical record showed Resident 62 received an influenza vaccine on 10/7/25, but no consent for the vaccine was found in the record. Staff 15, RN/IP, stated residents were offered influenza vaccines when available and a consent was signed prior to receiving the vaccine, and verified both residents did not have signed consents in their records. Staff 2, DNS, stated she expected all nursing staff to obtain a signed consent prior to giving any vaccinations.
Missing consent documentation for COVID-19 vaccinations
Penalty
Summary
The facility failed to ensure consents were obtained before administering COVID-19 vaccines to 2 of 5 sampled residents reviewed for vaccinations. The facility’s Infection Prevention & Control COVID-19 Immunization policy, revised 1/7/25, stated that all residents would be offered the COVID-19 vaccine when available and that the resident’s medical record would contain documentation of acceptance or refusal of the vaccine. Resident 9 was admitted in 1/2023 with diagnoses including paralysis of the left side following a stroke and diabetes, and a 10/23/25 Quarterly MDS indicated the resident was cognitively intact. The medical record showed Resident 9 received a COVID-19 vaccine on 10/2/25, but no consent was found in the record. Resident 62 was admitted in 6/2024 with diagnoses including end stage renal disease and paralysis of the left side following a stroke, and a 12/21/25 Quarterly MDS indicated the resident was cognitively intact. The medical record showed Resident 62 received a COVID-19 vaccine on 10/7/25, but no consent was found in the record. Staff 15, RN/IP, stated that residents were offered COVID-19 vaccines when available and that a consent was signed prior to receiving the vaccine, and verified that both residents did not have signed consents. Staff 2, DNS, stated she expected nursing staff to obtain a signed consent prior to giving any vaccinations.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to provide RN coverage for eight consecutive hours per day, seven days per week, as required, on 21 of 78 reviewed days between August and November 2025. Review of the Direct Care Staff Daily Reports for 8/2025, 9/2025, 10/2025, and 11/2025 showed that on multiple specific dates in each of those months there was no RN documented as being on duty for the required eight-hour period. Staff interviews revealed that staff were only instructed to begin reporting the RN manager on the Direct Care Staff Daily Report starting 1/13/25, and the Administrator stated that staff were expected to call off work two hours before their shift to allow time to find coverage. Surveyors requested payroll documentation to verify RN work on the identified dates, but no additional documentation was provided, and the deficiency was cited as placing residents at risk for unmet assessment needs. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency was based on staffing records, staff interviews, and the absence of corroborating payroll documentation for RN coverage on the listed dates.
Failure to Process and Track Resident Grievance for Missing Personal Property
Penalty
Summary
The deficiency involves the facility’s failure to promptly process and resolve a resident grievance related to missing personal property, as required by its Resident Rights Grievances Policy and Procedure. The policy, revised in 3/2023, assigns the grievance officer responsibility for overseeing the grievance process, receiving and tracking grievances through conclusion, leading investigations, maintaining confidentiality, and issuing written grievance decisions. It also requires staff to immediately report any grievance alleging misappropriation of resident property to the grievance officer, with reports to be made available within seven business days and a summary report of the investigation available to the resident. Despite these requirements, the facility’s grievance list for 7/2025 and 8/2025 contained no grievances for the resident in question. The resident, admitted in 2/2025 with a diagnosis including depression and documented as cognitively intact with a BIMS score of 15 on an 8/31/25 MDS, reported missing jewelry, an oximeter, and art supplies in 8/2025. The resident stated these missing items were reported both to staff and during a resident council meeting, and the 8/26/25 Resident Council minutes reflected that residents reported missing items from their rooms, with this resident in attendance. A CNA reported that the resident told her in 8/2025 about missing earrings and an oximeter and that she reported this to the charge nurse, but did not assist with another grievance form because the resident had completed one the day before. The Director of Social Services and Recreation stated he did not remember any grievances for this resident regarding missing items and that no grievances were found for the resident for 8/2025, suggesting the grievance may have been submitted but lost due to confusion among multiple staff. The Administrator stated he would have expected staff to complete a grievance and have it resolved within five days, which did not occur in this case.
Failure to Report Resident Elopement as a Facility-Reported Incident
Penalty
Summary
The facility failed to report an incident of potential neglect related to an elopement involving Resident 28 to the State Survey Agency. Resident 28, admitted in February 2025 with diagnoses including anxiety and a cognitive communication deficit affecting expressive and receptive language, was found on 3/6/25 at approximately 4:30 PM about a block away from the facility next to a busy street. An Elopement Investigation Report dated 3/7/25 documented that the root cause of the incident was the resident’s confusion and a non-functioning wander guard (electronic monitoring device). Despite this documented elopement event and investigation, there was no evidence that the incident was reported to the State Survey Agency. During interviews, the former Administrator (Staff 40) stated she could not remember if the elopement was reported and indicated she would not report an elopement because it was no longer listed on the Facility Reported Incident (FRI) form. The current Administrator (Staff 1) stated that, to his knowledge, no FRI was completed for the resident’s elopement, and the Regional RN (Staff 22) stated that if there was an alleged violation, it would be expected that an FRI be submitted for an elopement.
Failure to Monitor Wander Guard and Document Safety Checks for Wandering Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and ensure proper monitoring for a resident with severe cognitive impairment and a history of wandering. The resident was admitted with anxiety and a cognitive communication deficit, and an admission MDS documented a BIMs score of three, indicating severe cognitive impairment. A care plan dated 3/4/25 identified episodes of wandering and ordered a Wander Guard to be placed on the resident’s wheelchair, with interventions including checking the Wander Guard placement on every shift and using diversions such as activities, food, conversation, television, and books. A TAR initiated in 3/2025 instructed staff to check the Wander Guard placement on the left area of the wheelchair every shift. However, there was no documented evidence in the clinical record that staff were checking the Wander Guard to ensure it was functioning properly. On 3/6/25, an elopement occurred in which the resident was found approximately one block away from the facility next to a busy street. An Elopement Investigation Report identified the root cause as the resident’s confusion and a non-functioning Wander Guard. A former physical therapist assistant reported finding the resident very confused and in a precarious position near the busy street and stated that a CNA assisted in returning the resident to the facility. The CNA reported that the resident did not have a Wander Guard on the wheelchair at that time. Although the resident was placed on 15‑minute checks with a monitoring sign‑up sheet created, there was no documented evidence in the clinical record that staff conducted these 15‑minute checks following the elopement. The administrator confirmed that no 15‑minute monitoring sheets could be located and stated that it would be expected for staff to check Wander Guard placement and functionality.
Resident Instructed to Urinate in Bed Rather Than Transfer Independently
Penalty
Summary
A resident with a history of hip fracture and fibromyalgia, who was cognitively intact and required moderate staff assistance for transfers, reported being told by a speech therapist to urinate in bed if staff were not available to assist with toileting, rather than attempting to transfer independently. The resident described this comment as mortifying and degrading. The speech therapist stated she did not recall the specific resident but acknowledged that she instructs residents to follow safety recommendations and, if aware of unsafe transfer attempts, would advise urinating in bed rather than risking injury by transferring alone. The interim Director of Nursing Services did not recall the incident or the resident but stated that staff are expected to treat all residents with dignity and respect.
Failure to Administer Medications and Monitor Wound Care per Orders
Penalty
Summary
The facility failed to administer medications according to provider orders and did not properly monitor a surgical wound for a resident admitted with a hip fracture and fibromyalgia. Medication administration records showed that Tramadol was not given on several occasions due to the facility not obtaining the medication from the pharmacy, and Oxycodone supplies also ran out, requiring emergency orders. Progress notes and interviews confirmed that the resident experienced significant pain on days when medications were missed, and both the resident and a family member reported multiple instances of being without pain medication. Staff interviews revealed lapses in medication reordering and administration, with admissions that medications were sometimes missed or late due to ordering issues. Additionally, after a change in wound care orders to a honeycomb dressing, there were no instructions for ongoing wound monitoring, and staff did not implement further wound observations or treatments. The resident subsequently developed signs of infection, including fever, chills, and wound redness, and was sent to the emergency department for treatment. Staff interviews indicated that wound care monitoring was expected but not consistently performed, and multiple attempts to reach the wound care nurse were unsuccessful.
Inadequate Staffing Leads to Delayed Care and Missed Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in missed or delayed care, missed or late meals, and increased safety risks. Observations revealed call light wait times of up to 40 minutes, and grievances highlighted instances where residents were left in soiled briefs for extended periods, missed showers, and received late meal trays. The facility's staffing records showed consistent shortages of Certified Nursing Assistants (CNAs) across multiple months, contributing to these deficiencies. Residents and their families reported numerous issues related to inadequate staffing. Residents frequently experienced long wait times for call lights to be answered, leading to missed incontinence care and delayed meals. Some residents were found soaked in urine, and others missed showers or had to wait for assistance with meals. Family members also observed these issues, with some taking it upon themselves to provide basic care, such as changing soiled briefs and emptying urinals, due to the lack of staff response. Staff members corroborated these accounts, describing the staffing situation as inadequate for the high acuity level of residents. They reported being unable to complete care tasks, such as showers and personal hygiene, and having to perform two-person transfers alone. The facility's staffing coordinator admitted to not staffing based on residents' acuity or needs, further exacerbating the problem. This systemic issue led to a failure in providing timely and adequate care to residents, as evidenced by the numerous grievances and staff testimonies.
Failure to Follow Oxygen Administration Orders
Penalty
Summary
The facility failed to follow physician's orders related to oxygen administration for a resident diagnosed with respiratory failure with hypoxia and asthma. The resident was initially admitted with an order for continuous oxygen at 2 liters per minute via nasal cannula, which was discontinued upon their transfer to the hospital. Upon readmission, the resident did not have an order for oxygen. On a specific date, a staff member confirmed that the resident attended an appointment without an oxygen tank, resulting in a pulse oxygen reading of 64%. Observations on subsequent dates revealed the resident using a nasal cannula with an oxygen concentrator set at four liters per minute, despite no documented order for this level of oxygen. Staff confirmed the resident was on continuous oxygen without an order, and the Director of Nursing Services was informed of the situation.
Resident Injured Due to Staff's Physical Abuse and Neglect
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by staff, resulting in physical injury. The incident involved a resident who was admitted with a stroke and had moderate decision-making impairment due to aphasia. The resident communicated using yes or no questions and gestures. On the day of the incident, a CNA was reassigned from her usual duties to provide direct care to residents, which led to her becoming angry. In her frustration, she pushed the resident's shower chair hard out of the shower room, causing the resident's toe to hit the door, resulting in a lifted toenail and bleeding. The CNA left the resident alone in the room without a call light and did not report the incident to another CNA. Multiple staff members, including another CNA and unit managers, confirmed the sequence of events, noting that the CNA left the resident in a vulnerable state, with only a towel on and the water running. The DNS acknowledged that the CNA did not complete a proper hand-off or report before leaving the floor, which contributed to the resident's mistreatment and injury.
Inadequate Supervision and Safety Protocols in LTC Facility
Penalty
Summary
The facility failed to provide adequate supervision for Resident 55, who was diagnosed with dysphagia and dementia. Despite the care plan requiring supervision during meals, Resident 55 was repeatedly observed eating alone in the dining room and in their room without staff presence. This lack of supervision posed a significant risk to the resident's safety, particularly given their difficulty swallowing and cognitive impairments. Resident 93, who had a history of dementia, stroke, alcohol abuse, and seizures, was allowed to leave the facility without proper supervision or signing out, as required by the facility's elopement prevention guidelines. The resident was missing for nearly 24 hours, during which time they were found by law enforcement five miles away from the facility with a non-functioning power wheelchair. Staff interviews revealed a lack of concern and adherence to protocol, as the resident was known to leave the facility unsupervised, despite being cognitively and physically unable to do so safely. Resident 164, who had a history of falls and cognitive impairment, fell from an elevated bed, resulting in fractures to both legs. The resident's care plan included interventions to prevent falls, but the bed was consistently kept at a high position, contrary to standard care practices. Staff failed to ensure the bed was in a low position or to provide mats on the floor, contributing to the resident's fall. The incident highlighted a lack of adherence to safety protocols and inadequate risk assessment for the resident's known fall risks.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to serve food at appropriate temperatures and maintain sanitary conditions, which placed residents at risk for foodborne illnesses. One resident, who was cognitively intact and had a diagnosis of heart disease, reported being served moldy food. The former administrator confirmed that the resident called the police regarding the moldy food, and although the facility discarded perishable snacks, there was no verification of the food's condition. A Licensed Practical Nurse (LPN) saw photos of the food, which showed a sandwich with green mold and a fruit cup with white bumps, indicating the onset of mold. Additionally, the facility's dietary service logs recorded inadequate holding temperatures for chicken, poultry, and meatloaf, with no system in place to verify final cooking temperatures. The unit refrigerator was found in an unsanitary condition, with sandwiches lacking expiration labels, a broken shelf, and a sticky, uncleanable wooden shelf. The Infection Prevention Nurse confirmed the unsanitary conditions and the need for a cleanable surface shelf. Despite the addition of date labels on sandwiches, the overall condition of the refrigerator and surrounding area remained unchanged over five days.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to provide informed consent for the use of psychotropic medications to four out of five sampled residents. Resident 55, admitted with a pulmonary embolism, was prescribed sertraline and lorazepam without documentation of informed consent. Staff acknowledged a system issue related to providing risk and benefits information. Resident 87, diagnosed with bipolar disorder, received duloxetine without being informed of the risks and benefits, as confirmed by a Unit Manager. Resident 164, readmitted for surgical repair of leg fractures, was prescribed haloperidol and Ativan without obtaining consent, as social services staff were not present to obtain it. Resident 165, admitted after a stroke, was administered Lexapro without consent, with social services staff acknowledging the oversight. The lack of informed consent for these medications placed residents and their responsible parties at risk for lack of informed consent.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to provide a response to grievances raised by the Resident Council, which was identified as a deficiency. The grievance policy, revised in March 2023, required the grievance officer, typically the administrator, to take immediate action to prevent further potential violations of any resident rights while a grievance was investigated. However, the facility did not adhere to this policy. The Resident Council minutes from July and August 2024 documented several unresolved issues, including poor CNA performance, delayed meals, and mishandling of personal items. During a meeting in September 2024, residents expressed that their grievances were not addressed, and they received no follow-up, which affected their psychosocial well-being. The facility experienced frequent changes in administration, with three different administrators in the past year, leading to inconsistent communication and a lack of clarity regarding grievance handling responsibilities. Staff 7, the Activities Director, noted that grievances were given to department heads who were unaware of the proper procedures, resulting in a breakdown in the grievance process. The online grievance log lacked a follow-up section and did not specify who was responsible for addressing concerns. Staff 1 confirmed that there were no resolutions to the grievances, indicating a systemic failure in the facility's grievance handling process.
Unqualified Activities Director
Penalty
Summary
The facility failed to provide a qualified professional to direct the activities program, which was identified during an interview and record review. Staff 7, who was responsible for directing the activities program, including organizing the Resident Council, had been working in the activities department since May 2023 and was promoted to the Director position in July 2024. However, Staff 7 acknowledged that she did not have the required activities certification. This was confirmed by Staff 1, the Administrator, who admitted that the certification for Staff 7 was not completed as required. This deficiency placed residents at risk for unmet physical, mental, and psychosocial needs.
Failure to Ensure Residents Understand Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents understood the meaning of an arbitration agreement, which involves resolving disputes with a neutral party rather than in court. This deficiency was identified for three residents who were cognitively intact at the time of signing the agreement. Resident 19, admitted with a fracture of the left femur and chronic kidney disease, stated they knew what arbitration meant but did not remember signing the agreement. Resident 163, admitted with kidney and respiratory failure, remembered signing the agreement but their spouse had questions about the process and felt pressured to sign. Resident 262, admitted with respiratory failure and gout, did not remember signing the agreement and stated that arbitration was not explained during admission. Staff 59, the Admissions Coordinator, stated that she informed all new admissions of their right to decline or agree to arbitration and that they had 30 days to change their mind. She claimed to explain the definition and process of arbitration and offered a copy of the agreement to all admissions, providing her business card for any questions. Despite these claims, the residents and their representatives reported a lack of understanding and felt uninformed about the arbitration process, indicating a failure in communication and ensuring informed consent.
Infection Control Deficiencies in PPE Use and Equipment Handling
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices across multiple areas, including the use of personal protective equipment (PPE) and the handling of medical equipment. Observations revealed that staff members were not consistently wearing masks, particularly in areas with active COVID-19 cases. Additionally, PPE storage bins outside COVID-19 positive rooms were missing supplies, and staff were not wearing proper eye protection in these areas. The breakfast cart was observed with an uncovered tray, which was delivered to a resident's room, contrary to infection control protocols. Furthermore, the community use CBG glucometer was not sanitized between uses, posing a risk of bloodborne illness transmission. The laundry area also exhibited significant deficiencies, including a fan blowing from the dirty to the clean side, visible dirt on the fan, and inadequate air circulation. Equipment issues were noted, such as a leaking washing machine, a broken dryer heating element, and a washing machine with a broken door. These issues were acknowledged by staff, who indicated that repairs had been attempted multiple times without permanent resolution. Resident 20, who was cognitively intact and had a history of diabetes and infection, was directly affected by the improper sanitization of the CBG glucometer, as observed during a blood sugar check.
Deficiencies in Maintaining a Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for its residents, as evidenced by multiple deficiencies observed in the rooms of five residents. Resident 2's room was cluttered with various items, including an arctic air conditioner covered in thick dust, which had not been cleaned for three years despite the resident's requests for assistance. Resident 62's bathroom was found to be unclean, with urine and dark brown debris around the toilet bowl and yellow-colored debris on the floor, despite housekeeping efforts. Staff acknowledged these conditions, confirming the lack of a homelike environment. Additional deficiencies were noted in the rooms of Residents 98, 71, and 162. Resident 98's room had an unpainted wall patch that had been present since their move-in, and Resident 71 confirmed the patch was there during their stay. Resident 162 reported a broken window blind control wand, which was not recorded in the maintenance log, preventing the adjustment of blinds to let sunlight into the room. Maintenance staff confirmed the missing wand and acknowledged the dependency on nursing staff to report such issues, highlighting a communication gap in addressing maintenance concerns.
Failure to Document and Resolve Resident Grievances
Penalty
Summary
The facility failed to honor residents' rights to voice grievances without discrimination or reprisal, as evidenced by the lack of documentation and resolution of grievances for three residents and one unit. Resident 63, who was cognitively intact, reported a missing ring, but there was no grievance documentation or progress notes regarding the incident, despite the administrator's acknowledgment of the issue. Resident 98, also cognitively intact, reported rude treatment by staff and delays in care, but no grievance form was completed, and the administrator was unaware of the concern. Additionally, Resident 162, who was cognitively intact, reported moldy food and called the police, but there was no grievance form related to the issue, and the current administrator was not aware of the incident. Furthermore, a public complaint was received about untimely incontinence care and an unplugged call light, but only one grievance was documented for the month. Witness 4 reported multiple residents with unmet care needs, including missing blankets and skin breakdown due to lack of incontinence care, but these concerns were not documented in the grievance log. Staff 33 and the unit managers acknowledged the issues, but the grievances were not properly recorded or communicated to the administration, indicating a systemic failure in the facility's grievance handling process.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of residents, as evidenced by multiple complaints and observations of long call light wait times and unmet care needs. Residents reported waiting excessively for assistance, with some experiencing incontinence due to delays. Staff interviews confirmed that the facility was consistently short-staffed, leading to delays in care and incomplete tasks such as showers and meal assistance. Resident 24, who was cognitively intact and admitted with a diagnosis of heart disease, frequently experienced delays in receiving bowel and bladder care. On one occasion, the resident activated the call light for assistance, but staff did not respond promptly, resulting in the resident waiting with a soiled brief. This delay caused significant frustration and emotional stress for the resident, who also reported that staff did not wake them for meals, leading to cold food being left uneaten. Staff members expressed frustration with the staffing challenges, noting that they were unable to provide the necessary care to residents. The facility experienced high staff turnover and frequent call-offs, exacerbating the staffing shortages. Observations and interviews revealed that call light wait times often exceeded 30 minutes, with some instances reaching up to 99 minutes. The facility also faced challenges during outbreaks of norovirus and COVID-19, which further strained staffing resources.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to staff a registered nurse (RN) for eight consecutive hours per day, seven days a week, for seven out of 93 days reviewed. This deficiency was identified through a review of the Direct Care Staff Daily Reports covering specific periods from April to September 2024. The reports revealed that on seven days, there was no RN coverage for eight consecutive hours on any shift within a 24-hour period. This lack of consistent RN coverage placed residents at risk for unmet assessment needs. During interviews on September 13, 2024, the facility's administrator, director of nursing services (DNS), and regional nurse acknowledged the issue but did not provide additional information regarding the required RN coverage.
Failure to Document Census in Staffing Reports
Penalty
Summary
The facility failed to post accurate and complete staffing information for six consecutive days, which placed residents at risk for incomplete and inaccurate staffing information. On multiple occasions, the Direct Care Staff Daily Report lacked documentation of the census for various shifts. Specifically, on September 8th, no census was documented for the day and evening shifts, and the night shift posting was incomplete. Similar omissions occurred on September 9th, 10th, 11th, 12th, and 13th, with the day shift census missing on each of these days. During an interview on September 13th, the Administrator, Director of Nursing Services, and Regional Nurse acknowledged that staff should document the census for each shift on the report.
Failure in Safe Medication Self-Administration System
Penalty
Summary
The facility failed to ensure a safe system for a resident's self-administration of medication, which placed residents at risk for adverse medication reactions. Resident 44, who was admitted in 2021 with a diagnosis of heart disease and was cognitively intact, was assessed on a Self-Administration of Medication form to be capable of self-administering medications. However, the form did not specify which medications the resident could self-administer. The resident's care plan indicated that they self-administered over-the-counter supplements kept at their bedside, but it also failed to identify specific medications for self-administration. An incident occurred where Resident 44 mistakenly applied Desitin to an old skin graft donor site, which worsened the condition of the site. Observations revealed that the resident's room contained multiple bottles of supplements, creams, and liquid disinfectants, including a tube of Desitin, which were not secured as required. Staff acknowledged that medications were supposed to be locked in a secure area and that the resident had orders for only two supplements to be kept at the bedside. This oversight in medication management and storage led to the resident's adverse reaction and highlighted the facility's failure to maintain a safe self-administration system.
Failure to Assist Resident with Advance Directive
Penalty
Summary
The facility failed to assist a resident with formulating an advance directive, which is a deficiency in honoring residents' rights to make end-of-life choices. The resident, admitted in 2022 with chronic kidney disease, was cognitively impaired but able to express needs and desired to create an advance directive with the help of a friend. During an IDT Care Plan Conference, this wish was noted, but from the period of late July to early September, there was no documentation of follow-up or communication with the resident or their friend regarding the advance directive. A staff member from Social Services acknowledged the resident's request but could not provide any documentation of assistance being offered or completed.
Failure to Investigate Resident Injury
Penalty
Summary
The facility failed to thoroughly investigate an injury involving a resident who was admitted with a diagnosis of stroke. On the day of the incident, a CNA was responsible for showering the resident and accidentally bumped the resident's foot against the wall while exiting the shower room. The CNA left the facility before the end of her shift, leaving the resident sitting in the shower chair. Another CNA later found the resident's toe bleeding, with no prior report or communication about the incident. The facility's investigation, conducted by a Unit Manager-LPN, did not include interviews with the resident, other CNAs, or nurses involved. A staff member reported that the CNA became angry due to a reassignment and pushed the resident's shower chair hard, causing the resident's toe to hit the door, resulting in a lifted toenail and significant bleeding. The CNA left the resident alone in the room without a call light and did not inform another CNA of her departure.
Failure to Notify Ombudsman of Resident Hospitalizations
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman regarding the hospitalization of two residents, which is a requirement to ensure residents have access to an advocate who can inform them of their options and rights. Resident 95, who was admitted with a diagnosis of cancer, requested to be sent to the hospital for shortness of breath. Emergency services were called, and the resident was transferred to the hospital. However, there was no documentation in the resident's clinical record indicating that the State Long-Term Care Ombudsman was notified of this transfer. Similarly, Resident 262, admitted with diagnoses including anxiety and a leg fracture, was transferred to the hospital for a disimpaction procedure after experiencing severe pain. Despite being cognitively intact, as indicated by a BIMS score of 15, there was no documentation of a transfer notice with appeal rights being provided to the resident or notification to the Ombudsman. Staff interviews revealed that the medical records staff, who were responsible for sending discharge information to the Ombudsman, did not complete these notifications.
Failure to Provide Bed Hold Policy to Hospitalized Residents
Penalty
Summary
The facility failed to provide a bed hold policy to two residents who were transferred to the hospital, which is a requirement to ensure residents are informed of their right to return to the facility. Resident 95, who was admitted with a diagnosis of cancer, was transferred to the hospital for shortness of breath. There was no documentation in Resident 95's clinical record indicating that a bed hold policy was provided at the time of discharge. Staff members, including those from social services and admissions, were unsure of who was responsible for providing the bed hold policy, and it was confirmed that the policy was not present in the resident's record. Similarly, Resident 262, admitted with anxiety and a leg fracture, was transferred to the hospital for a disimpaction procedure. The resident's clinical records lacked documentation of a bed hold policy being provided in writing at the time of transfer. The resident, who was cognitively intact, stated they were unaware of the bed hold policy. The facility's administrator and director of nursing services confirmed that no bed hold notice was given to Resident 262 upon transfer to the hospital.
Failure to Revise Care Plans for Personal Equipment and Medications
Penalty
Summary
The facility failed to revise care plans for three residents, leading to potential unmet needs. Resident 2, admitted in May 2016 with chronic pain, had a mini arctic air conditioner and a suction machine in their room, but these were not documented in the care plan as of July 2024. This oversight was acknowledged by the Unit Manager-LPN during an observation in September 2024. Resident 86, admitted in March 2024 with depression and paraplegia, had a care plan revised in June 2024 that lacked specific interventions for anxiety and personal preferences for dressing and shaving. Staff noted the resident required encouragement to accept care due to anxiety, and the resident expressed a preference for being clean-shaven and choosing clothes when leaving the facility. The absence of these details in the care plan was confirmed by the Social Services staff. Additionally, Resident 165, readmitted in August 2024 post-surgery, had a care plan from 2022 that did not include interventions for the use of haloperidol and Ativan, nor monitoring for adverse reactions or triggers for anxiety. The LPN Resident Care Manager acknowledged that the care plan was not updated.
Failure to Provide Meaningful Activities for Residents
Penalty
Summary
The facility failed to provide meaningful activities for two residents, leading to a lack of social interaction and potential isolation. Resident 14, who has dementia and depression, expressed a desire to engage in favorite activities and go outside. However, observations revealed that the resident often sat in the hallway with nothing to do and was bored. The resident's care plan was not updated to reflect the discontinuation of their electric wheelchair, which limited their ability to go outside independently. Additionally, the activities staff did not attend care conferences, resulting in a lack of support for the resident's activity needs. Resident 54, diagnosed with depression and anxiety, also experienced a lack of engagement in activities. Despite expressing interest in activities such as crocheting, the resident reported that staff did not inquire about their interests. The activities department faced staffing challenges, which contributed to incomplete assessments and a failure to capture important information about residents' preferences. The absence of activities staff at care conferences further hindered the facility's ability to meet the residents' needs.
Failure to Provide Hearing Services
Penalty
Summary
The facility failed to follow through on necessary hearing services for a resident, leading to a deficiency in maintaining adequate hearing. The resident, admitted in March 2024 with diagnoses including depression and paraplegia, was identified during a care plan conference in May 2024 as requiring hearing services, specifically ear cleaning. Despite this, a quarterly assessment at the end of May indicated the resident had no hearing aids and adequate hearing. However, by September, staff acknowledged the resident had hearing issues and ongoing ear wax build-up, which was supposed to be addressed through physician orders. The Unit Manager confirmed that she neglected to obtain the necessary physician orders for ear wax removal, resulting in a lack of follow-through on the required services.
Delayed Assessment and Treatment of Pressure Ulcer
Penalty
Summary
The facility failed to ensure timely assessment and treatment of a pressure ulcer for a resident who was admitted with no pressure ulcers but was at risk due to incontinence and required assistance for repositioning. On a specific date, a CNA reported an open area on the resident's coccyx, but no comprehensive assessment was conducted until three days later. The wound was identified as a Stage 3 pressure ulcer with significant slough, and it was determined to be facility-acquired. Treatment was not documented as completed until four days after the initial report. The delay in assessment and treatment was partly due to the LPN's understanding that staging a pressure ulcer was outside their scope of practice, and the absence of a comprehensive assessment by an RN, despite one being present in the building. The facility's staff acknowledged the delay in staging and measuring the ulcer, which should have been done when the pressure ulcer was first identified.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care and services according to physician orders and standards of practice for three residents. Resident 2, admitted with chronic pain, had a suction machine in their room that was covered in dust and had not been used for years, despite a physician order to check and replace the canister weekly. The unit manager acknowledged the oversight and confirmed the machine should have been removed as it was not in use. Resident 55, admitted with a pulmonary embolism, had orders for oxygen therapy to maintain oxygen saturation levels above 90 percent. However, from the beginning of September, there was no documentation of oxygen administration, and observations confirmed the resident was not receiving oxygen. The facility staff were unsure if the orders were PRN, and the hospice medication list provided was not a signed physician's order. Resident 87, with respiratory failure and congestive heart failure, was to receive inhalation medication but had their nebulizer improperly stored and without clear instructions for cleaning and maintenance. The unit manager acknowledged the need for proper cleaning and storage instructions.
Failure to Administer PRN Pain Medication as Ordered
Penalty
Summary
The facility failed to provide pain medications as ordered for a resident admitted with a leg fracture and pain due to internal orthopedic prosthetic devices. The resident, who was cognitively intact with a BIMS score of 15, experienced frequent pain affecting sleep quality and daily activities, with pain levels reaching up to 10 on a scale of zero to 10. The medication administration record (MAR) for September instructed staff to administer oxycodone 5 mg every four hours PRN for moderate pain, with specific dosages based on pain levels. On September 7, the resident was administered 10 mg of oxycodone at 1:07 AM, 5:14 AM, and 12:11 PM for pain levels of eight and 10. However, the resident reported activating the call light at 9:15 AM on September 7 to request PRN pain medication, but no staff responded until 12:00 PM when lunch was delivered. Staff interviews revealed that the resident was consistent in requesting PRN pain medications, but due to low staffing levels and high workload, the medication was not administered as needed. Staff 46, who was responsible for administering the medication, stated that she might not have been informed of the resident's request and was assigned to both units, which may have prevented her from administering the medication. The facility's administration confirmed the expectation to provide pain medications as ordered by the physician and to follow through with PRN requests.
Failure to Provide Proper Post-Dialysis Care
Penalty
Summary
The facility failed to provide appropriate post-dialysis care and services for a resident with end-stage renal disease who was dependent on renal dialysis. The resident, who was cognitively intact, reported that staff did not check her/his fistula or vitals upon return from dialysis sessions. The resident's care plan required monitoring for infection at the fistula site, bleeding, and symptoms of kidney malfunction, as well as checking the thrill and bruit of the fistula. However, the Medication Administration Records (MARs) and Treatment Administration Records (TARs) from June to September 2024 did not include orders for these necessary checks, and the order to check the thrill and bruit was discontinued in June 2024. The resident had 45 opportunities to attend dialysis sessions between June and September 2024, but the facility completed pre-dialysis paperwork only 35 times and post-dialysis paperwork just four times. Staff interviews revealed that the pre-dialysis forms were sometimes lost, and there was poor communication with the dialysis center. The Unit Manager acknowledged the missing documentation and the lack of an order for checking the thrill and bruit, indicating a failure to adhere to the care plan and ensure proper post-dialysis monitoring.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 133 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Eugene
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avamere Riverpark Of Eugene | 2 mi | ★★★★★ | 14 | 0 |
| Marquis Springfield | 3.4 mi | ★★★★★ | 25 | 0 |
| South Hills Rehabilitation Center | 3.9 mi | ★★★★★ | 22 | 1 |
| Cascade Manor | 4.2 mi | ★★★★★ | 4 | 0 |
| Avamere Rehabilitation Of Eugene | 4.3 mi | ★★★★★ | 17 | 1 |
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 July 2026) and official state health department websites.