Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hillside Heights Rehabilitation Center during CMS and state inspections, most recent first.
A resident with diabetes, polyneuropathy, and a left great toe wound did not receive ongoing, comprehensive wound assessments as required by facility guidelines. Initial documentation from a wound clinic and a Skin and Wound Evaluation recorded wound size, tissue types, and drainage, but omitted key assessment elements such as wound edges, swelling, temperature, pain, treatment type, and care goals. After a later clinic note documented regression of the toe wound and aggressive debridement, no further Skin and Wound Evaluations were found in the record. A complaint was filed alleging the toe became infected due to negligence, and the resident reported continued pain. An LPN stated she performed wound care before discharge and noted only dried blood and blanchable redness, while the DNS acknowledged that, following the loss of a dedicated wound nurse, it was difficult for staff to complete the expected weekly wound assessments.
A resident with obstructive and reflux uropathy and a suprapubic catheter had physician orders for catheter changes every 30 days, but one scheduled change was placed on hold while staff awaited instructions due to a mistaken belief the resident had a penile implant, and there was no documentation that the catheter was changed. In a later month, the TAR showed an LPN documented completing a suprapubic catheter change without any supporting progress note, and the LPN later reported likely charting the treatment without performing it. The resident reported bladder pain and spasms and requested a urinalysis, the physician ordered the test, but the record showed no evidence it was completed, while staff interviews revealed uncertainty about responsibility for catheter changes and acknowledgment by the DNS that staff focused on the resident’s pneumonia instead of the ordered urinalysis.
An unlocked and unattended treatment cart was observed on the west hall while it contained insulin and other treatments. An open insulin glargine pen in the west hall cart and an open Tresiba insulin pen in the east hall cart were both found without open dates, and an LPN and RN acknowledged the unlabeled insulin pens.
Failure to Follow Bowel Protocol and Ordered Bowel Care: Two residents, including one with diabetes and one with heart failure, had multiple days without a documented BM. The bowel records, progress notes, and MARs showed no nurse bowel assessments were completed and no additional bowel meds were offered as required by the facility bowel protocol and physician orders; the DNS acknowledged the missed assessments and interventions.
Controlled substance records were not kept in order for 2 of 3 med carts reviewed. An LPN completed a narcotic count but did not sign the Controlled Substance Book at the time, and an RN administered oxycodone to a resident while the pill count on the med card did not match the book. The DNS stated two staff were expected to count controlled meds between shifts, compare counts to the book, and both sign after the count.
Digoxin was administered to a resident with atrial fibrillation without documented pulse checks before each dose. The record lacked digoxin parameters, and an RN, an LPN, and the DNS stated staff sometimes relied on CNA vital signs from the EHR instead of checking the pulse immediately before giving the medication.
Medication error rate exceeded the allowed threshold after surveyors found 2 errors in 27 opportunities for a 7% rate. An RN was observed giving a resident's morning meds without ordered Lasix and Lactulose, and later acknowledged the resident did not receive those meds because they were not available. The resident had atrial fibrillation and orders for Lasix for edema and Lactulose for increased ammonia levels.
A resident with heart failure and poor dentition requested a dental appt at a care conference, but staff did not follow up and no dental visit was arranged. The clinical record had no documentation showing the request was completed, and the DNS acknowledged the appt was never set up.
A resident with atrial fibrillation had an order for digoxin 250 mcg daily, but the MAR documented digoxin 250 mg instead. The DNS stated the discrepancy was due to a transcription error when the medication was entered into the MAR.
The facility did not complete timely investigations for two residents: one who experienced an unwitnessed fall and another who was diagnosed with a sexually transmitted infection despite significant cognitive impairment. In both cases, required investigations into the incidents were either delayed or not documented, contrary to facility expectations.
A resident with a history of unsteadiness and traumatic brain injury experienced multiple falls, including one unwitnessed fall caused by malfunctioning bed brakes. Although the care plan included interventions for fall prevention, there was no documentation of required monthly bed brake checks or related maintenance work orders. Staff confirmed the brakes were not functioning at the time of the incident, and it was expected that staff check bed brakes before leaving the room.
A resident with dysphagia and dementia, who was care planned to need supervision or touch assistance with eating, was observed left alone with a meal tray and received no assistance during mealtime. Staff later removed the tray with most of the food uneaten, and confirmed they were aware of the resident's need for eating assistance but could not recall providing it.
A resident with a history of stroke and anxiety experienced delays in obtaining an ordered STI risk panel due to incomplete laboratory requisitions and issues with specimen collection. Despite urgent clinical symptoms and repeated attempts, the required testing was not completed, and the resident was eventually sent to the emergency department for further evaluation.
The facility failed to provide menus for residents to select their preferred meals, affecting their ability to make choices. Despite a change to a weekly menu system, residents reported not receiving these menus, leading to dissatisfaction and unmet preferences. Staff confirmed the change and the resulting resident dissatisfaction.
The facility's kitchen was found to have several sanitation and food storage deficiencies, including undated and improperly stored food items in the walk-in refrigerator and freezer, and a lack of temperature monitoring for a small refrigerator containing resident food items. The kitchen area also had unclean surfaces and floors, with food crumbs and debris present. Staff were unaware of temperature monitoring procedures, and the Dietary Manager acknowledged these issues.
An LPN at the facility failed to demonstrate appropriate competencies in infection control and insulin administration. The LPN did not clean the glucometer after CBG checks and did not prime the insulin pen as per manufacturer instructions. The LPN, new to the facility and in her first nursing job, was not aware of these procedures and had not undergone competency checks, as confirmed by the DNS.
The facility did not have an RN available for at least eight consecutive hours on three days, risking delayed nursing assessments for residents. This was confirmed through staff reports and acknowledged by the administrator.
The facility failed to maintain proper storage temperatures for a medication refrigerator, with temperatures reaching 73°F, affecting flu vaccines and insulin. Additionally, two open Tresiba insulin pens lacked open dates, and a treatment cart was left unlocked twice, risking unauthorized access. Staff acknowledged these issues.
The facility failed to ensure a homelike environment for residents, with issues such as a loud air conditioner, a burned-out bathroom light, peeling window paint, and a strong urine odor in a resident's room and wheelchair. Staff acknowledged these issues, but there was no documentation of corrective actions taken.
A resident prescribed Trazodone for insomnia did not receive information about the medication's risks and benefits, hindering informed decision-making. The resident, with a history of depression, anxiety, and insomnia, was unaware of any discussion or consent regarding the medication. An LPN confirmed the lack of documentation on this matter.
The facility failed to document advance directives for three residents, including one with depression and two with diabetes. The Director of Social Services confirmed the lack of documentation and was unable to provide evidence that advance directives were offered or reviewed with the residents or their families.
The facility failed to provide proper respiratory care for two residents, leading to deficiencies in oxygen administration and equipment maintenance. One resident's oxygen concentrator filters were not cleaned weekly as ordered, while another resident received oxygen at a higher rate than prescribed, with tubing not changed regularly, resulting in crusty debris. Staff confirmed the lack of documentation and absence of a facility policy for these tasks.
A facility failed to clean a community use CBG glucometer between resident uses, risking bloodborne illness. An LPN was observed not cleaning the glucometer after use and admitted to cleaning it only at shift start and end, without knowing the location of the required wipes. The DNS confirmed the expectation for cleaning with bleach wipes between uses, and a Corporate RN noted residents requiring regular and PRN CBG checks.
The facility failed to maintain essential kitchen equipment in safe operating condition, as the walk-in refrigerator's door handle was missing. Dietary staff acknowledged the issue, but the handle remained unrepaired during a follow-up visit. A dietitian noted the need to locate and reattach the handle.
Failure to Perform Ongoing Assessments for Diabetic Foot Wound
Penalty
Summary
The deficiency involves the facility’s failure to ensure ongoing, comprehensive assessments and documentation for a non-pressure skin wound on a resident’s left great toe, as required by its Skin and Wound Management Guidelines. Those guidelines specified that neuropathic ulcers and vascular-related wounds required assessment, measurement, photography, and documentation in the Skin and Wound Module. The resident, admitted with an open wound of the left great toe and diabetes with polyneuropathy, had an admission MDS indicating a diabetic foot ulcer. A wound clinic note documented an incised blister on the left great toe with drainage and a wound surface area of 20 cm² or less. A subsequent Skin and Wound Evaluation recorded an “other wound” on the first digit of the left foot with specific length and width measurements, a wound bed containing epithelial, granulation, and slough tissue, and moderate serosanguineous drainage. However, this Skin and Wound Evaluation did not include required elements such as assessment of wound edges, swelling, temperature, pain, treatment type, or the care goal. A later wound clinic note indicated the left great toe wound had regressed and was aggressively debrided, with callus, fibrin, and slough removed, but there was no documented evidence of any further Skin and Wound Evaluations after that date. The state survey agency received a complaint alleging the resident developed an infected toe due to facility negligence, and the resident later confirmed the complaint and ongoing toe pain. An LPN reported performing wound care the day before discharge and recalled only slight dried blood and blanchable redness, with no black discoloration or signs of infection, and stated that weekly wound assessments were set to trigger automatically and typically completed by a wound nurse. The DNS stated he expected weekly skin and wound assessments but acknowledged the facility no longer had a wound nurse due to budget cuts, making it difficult for nurses to complete the weekly evaluations.
Failure to Provide Ordered Suprapubic Catheter Care and Urinalysis
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate suprapubic catheter care and to complete ordered diagnostic testing for a resident with obstructive and reflux uropathy. The resident was admitted with a suprapubic catheter and had physician orders on the Treatment Administration Record (TAR) for catheter changes every 30 days. In one month, the TAR entry was placed on hold with a note to see Administration Notes, which documented that the catheter was not changed while staff awaited special instructions from the in-house provider due to a presumed penile implant. There was no documentation that the catheter was changed that month. The following month, the TAR again indicated a 30‑day suprapubic catheter change, and the TAR showed that an LPN had completed the change on a specific date, but there was no corresponding progress note documenting that the procedure occurred. Subsequently, the resident reported bladder pain and spasms to an LPN and requested a urinalysis, believing there was an infection. The physician ordered a urinalysis, but the clinical record contained no documentation that the urinalysis was completed. Two public complaints were submitted to the State Survey agency stating that the resident’s suprapubic catheter had not been changed since admission and that the resident believed there was a urinary tract infection. During interviews, one LPN stated she was unsure whether the catheter should be changed at the facility or at a urology clinic and did not know if the catheter had been changed in the earlier month. Another LPN stated she did not recall ever changing the resident’s catheter and believed she likely documented completion of the suprapubic catheter change without actually performing it. The DNS acknowledged that documentation was lacking regarding follow‑through on the communication about a penile implant, that staff had mistaken the suprapubic catheter for an implant, and that staff focused on the resident’s pneumonia instead of the ordered urinalysis, resulting in the urinalysis not being performed and physician‑ordered treatment not being completed.
Unsecured treatment carts and unlabeled insulin pens
Penalty
Summary
The facility failed to ensure drugs and biologicals were labeled in accordance with accepted professional principles and failed to keep treatment carts properly secured. During observation, the west hall treatment cart near the nurses' station was left unlocked and unattended while it contained insulin and other treatments. An open insulin glargine pen was also observed in the west hall treatment cart with no open date, and Staff 8, an LPN, acknowledged that the pen was open and unlabeled. In a separate observation, an open Tresiba insulin pen was found in the east hall treatment cart with no open date, and Staff 7, an RN, acknowledged that the pen was open and not labeled with an open date.
Failure to Follow Bowel Protocol and Ordered Bowel Care
Penalty
Summary
The facility failed to follow its bowel protocol and failed to administer bowel-related medications as ordered for two residents reviewed for medication management. The undated bowel protocol stated that residents without a bowel movement for more than three days were to receive a nurse assessment, including a physical GI assessment, review for signs and symptoms of constipation, impaction, or obstruction, and a resident and/or staff interview. When indicated, the protocol called for bowel interventions based on physician orders, and if no bowel movement occurred after completion of the protocol, the physician was to be notified. One resident, admitted with diabetes, had no documented bowel movement for five consecutive days, and the bowel records, progress notes, and MARs showed no bowel assessments were completed and no additional bowel medications were offered during that period. Another resident, admitted with heart failure, had no documented bowel movement for four consecutive days, and the bowel records, progress notes, and MARs likewise showed no bowel assessments were completed and no additional bowel medications were offered. The DNS acknowledged that bowel assessments were not completed for both residents and that they did not receive bowel care interventions as ordered on the identified dates.
Controlled Substance Count and Documentation Errors
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility failed to ensure residents' narcotic drug records were in order and that an account of all controlled drugs was maintained for 2 of 3 medication carts reviewed for medication storage. On 1/28/26 at 8:38 AM, the west hall Controlled Substance Book showed only one signature for the day shift controlled medication count; Staff 8, an LPN, then signed the book and stated he had completed the count earlier that morning with another staff member but had not signed the book at that time. On 1/28/26 at 9:23 AM, Staff 7, an RN, administered oxycodone to Resident 19 and signed it out of the Controlled Substance Book, but there were four pills remaining after administration while the book indicated five remaining. Staff 7 stated she had completed the controlled medication count with the night shift nurse but they missed the discrepancy between the oxycodone medication card and the book. On 1/30/26 at 11:39 AM, Staff 2, the DNS, stated the expectation was for two staff to count controlled medications between shifts, compare them to the Controlled Substance Book, and each sign the signature page after the count was completed.
Digoxin Given Without Documented Pulse Checks
Penalty
Summary
The facility failed to ensure that Resident 5’s drug regimen was free from unnecessary drugs when digoxin was administered without documented pulse monitoring before each dose. Resident 5 was admitted with diagnoses including atrial fibrillation, and a 12/19/25 physician order directed digoxin 250 mcg once daily. The manufacturer recommendations stated the heart rate should be monitored for one full minute before administration and the health care provider notified if the heart rate was less than 60 beats per minute or if there were significant changes in pulse rate, rhythm, or quality. The clinical record did not show that staff checked Resident 5’s heart rate each time before giving digoxin. Staff 7 stated she held the medication if the pulse was below 60 but did not always check the pulse before administration, relying instead on recent CNA-recorded vital signs in the electronic health record. Staff 9 stated Resident 5 did not have digoxin parameters noted in the electronic health record and that she used CNA vital signs recorded within the last hour to decide whether to administer the medication. Staff 2 acknowledged the order had no parameters noted in the clinical record and stated staff were to check the resident’s pulse before administering digoxin and hold it if the pulse was too low.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
Medication error rates were not maintained below 5%, as surveyors found 2 errors in 27 opportunities for a 7% medication error rate. Resident 46, who was admitted in 2019 with diagnoses including atrial fibrillation, had physician orders dated 1/22/26 for Lasix every Monday, Wednesday, and Friday for lower extremity edema and Lactulose once daily for increased ammonia levels. On 1/28/26 at 8:42 AM, Staff 7, an RN, was observed administering the resident's morning medications, and Lasix and Lactulose were not included. At 8:54 AM, Staff 7 acknowledged that Resident 46 did not receive Lasix or Lactulose as ordered because the medications were not available.
Failure to Arrange Dental Services After Resident Request
Penalty
Summary
The facility failed to provide dental services for 1 of 3 sampled residents reviewed for dental services. Resident 7, who was admitted in 2023 with diagnoses including heart failure, had poor dentition noted in a 11/6/25 progress note. During the 11/26/25 care conference, Resident 7 expressed interest in having a dental appointment. On 1/26/26, Resident 7 stated that dental problems had been present and that a request to see the dentist had been made at the prior care conference several months earlier, but staff did not follow up on the request. The clinical record contained no information showing that the request for a dental appointment was completed, and on 1/29/26 the DNS acknowledged that Resident 7 wanted to see the dentist at the care conference and that a dental appointment was not set up.
Inaccurate MAR Documentation for Digoxin
Penalty
Summary
Medical records were not maintained accurately for 1 of 5 sampled residents reviewed for medication. Resident 5 was admitted with diagnoses including atrial fibrillation, and the 12/19/25 physician order directed digoxin 250 mcg once daily. However, the 12/2025 and 1/2026 MARs documented digoxin 250 mg from 12/20/25 through 12/31/25 and from 1/1/26 through 1/8/26. During interview on 1/29/26 at 1:15 PM, the DNS stated there was a transcription error when digoxin was entered into the MARs and acknowledged the MARs listed 250 mg instead of the ordered 250 mcg.
Failure to Timely Investigate Abuse Allegation and Resident Fall
Penalty
Summary
The facility failed to investigate a potential case of abuse and did not investigate a fall in a timely manner for two residents. One resident, admitted with unsteadiness on feet and a traumatic brain injury, experienced an unwitnessed fall while attempting to go outside. The investigation into this fall was not completed until nearly two weeks later, despite facility expectations that such investigations be completed within five days. Another resident, admitted with a history of stroke, anxiety, and significant cognitive impairment, was diagnosed with trichomonal vaginitis, a sexually transmitted infection, after presenting with persistent symptoms and being sent to the emergency department. Despite the diagnosis and a public complaint alleging a sexually transmitted disease, there was no documentation in the clinical record of an investigation into potential sexual abuse for this resident. Staff confirmed that an investigation into possible sexual abuse was expected but not completed.
Failure to Maintain Safe Environment Due to Malfunctioning Bed Brakes
Penalty
Summary
A deficiency occurred when the facility failed to maintain a safe environment free from accident hazards for a resident admitted with unsteadiness on feet and a traumatic brain injury. The resident experienced two falls on the day of admission, and a subsequent unwitnessed fall occurred when the resident rolled out of bed due to malfunctioning bed brakes. Although the baseline care plan included interventions such as a PT consultation and monitoring for changes in condition, the bed brakes in the resident's room were not functioning properly at the time of the fall. Maintenance staff stated that bed brakes were supposed to be checked monthly, but there was no documentation to verify these checks or any work orders related to the malfunctioning brakes during the relevant period. Nursing staff confirmed the bed brakes were not working at the time of the incident, and the DNS stated that staff were expected to check bed brakes before leaving a resident's room.
Failure to Provide Eating Assistance as Care Planned
Penalty
Summary
A resident with diagnoses of dysphagia and dementia, admitted in February 2025, was care planned to require supervision or touch assistance with eating due to an ADL self-care performance deficit. On observation, the resident was left alone in bed with a food tray and was unable to answer questions, with no staff present in the room. Staff later entered the room, asked if the resident was finished eating, and removed the tray despite approximately 90 percent of the food remaining. The staff member assigned to the resident confirmed knowledge of the care plan requiring one-person assistance and supervision for eating but could not recall if she had provided this assistance during the meal. The DNS confirmed that the staff working with the resident at the time did not know the resident and acknowledged the resident required assistance to eat.
Failure to Timely Process Physician Laboratory Orders
Penalty
Summary
The facility failed to process a physician's laboratory order in a timely manner for a resident admitted with a history of stroke and anxiety. A physician ordered a sexually transmitted infection (STI) risk panel, but the laboratory requisition was incomplete, lacking the necessary test code and name. The laboratory report indicated that no suitable specimen was received and requested clarification on test requirements. Despite the urgency noted on the requisition, the required Aptima swab was not provided, and the test was not performed. Subsequent clinical notes documented that the resident experienced ongoing symptoms, including foul-smelling vaginal discharge and new-onset hallucinations. The resident completed a course of antibiotics for a urinary tract infection (UTI) without improvement. Staff reported difficulties obtaining the required STI testing due to laboratory refusals and facility budget constraints. The Director of Nursing Services was unable to clarify what occurred with the laboratory results, and ultimately, the resident was sent to the emergency department for further evaluation.
Failure to Provide Menus for Resident Meal Preferences
Penalty
Summary
The facility failed to ensure a system was in place to honor resident food preferences, affecting four sampled residents. The deficiency was identified through observations, interviews, and record reviews. Residents, including those with diabetes and heart disease, reported not receiving menus to select their preferred meals. The facility had recently changed its menu system from providing daily menus to weekly menus distributed on Fridays. However, residents stated they did not receive these weekly menus, and staff confirmed that the change had upset several residents as it removed their ability to choose between meal options. Staff members, including CNAs and the dietitian, acknowledged the change in the menu system and the resulting dissatisfaction among residents. The facility's administrator stated that the change was discussed in Resident Council and at a food committee, but residents reported not being informed of these changes. The lack of menu distribution led to residents receiving meals without the opportunity to make choices, impacting their satisfaction and potentially their nutritional needs.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during an inspection. In the walk-in refrigerator, there were several issues including an opened and undated plastic container with pickle spears, a cardboard box of dark brown bananas, and an open stick of margarine exposed to air and undated. The floor of the refrigerator was littered with food crumbs, brown splatters, and various small debris. Similarly, the walk-in freezer contained a bag of frozen tapioca hot dog buns with an expiration date of 12/22/22, and several opened and undated bags of frozen chicken strips, hamburger patties, and veggie vegan patties. A zip lock bag labeled pizza sausage was found to be freezer burnt with an illegible date. The freezer floor also had food crumbs and brown splatters of debris. In the main kitchen area, a wire rack next to a garbage can had metal containers with splatters of debris, and the bottom shelf of the steam table, where clean pots and pans were stored, had drips of white and brown debris. A wire shelf containing clean bowls was covered with a sticky brown film, and the floor throughout the main kitchen area was covered with food crumbs, brown splatters, and various small debris. Additionally, a small refrigerator containing juice, milk, and yogurt did not have a temperature log, and staff members were unaware of any temperature monitoring for this refrigerator. The Dietary Manager acknowledged these findings, indicating a lack of proper monitoring and maintenance of sanitary conditions in the kitchen.
LPN Lacks Competency in Infection Control and Insulin Administration
Penalty
Summary
The facility failed to ensure that a Licensed Practical Nurse (LPN), identified as Staff 13, possessed the necessary competencies and skills for infection control during capillary blood glucose (CBG) checks and insulin administration. On the specified date, Staff 13 was observed obtaining a CBG for a resident and subsequently placing the glucometer in the treatment cart without cleaning it. Continuous observations revealed that Staff 13 administered medications and insulin to multiple residents without cleaning the glucometer. Staff 13, who had been working at the facility for one month and was in her first nursing job, stated that she cleaned the glucometers only at the beginning and end of her shift and was not aware of any competency checks by the facility. Additionally, Staff 13 did not follow the manufacturer's instructions for administering Novolog insulin, as she failed to prime the insulin pen with two units before drawing up the insulin for administration. When questioned, Staff 13 acknowledged her lack of knowledge regarding the need to prime the insulin pen and reiterated that she had not undergone competency checks. The Director of Nursing Services (DNS), identified as Staff 2, confirmed that nursing competencies had not been completed for Staff 13, highlighting a lapse in ensuring staff were adequately trained and competent in their duties.
Failure to Ensure RN Coverage for Eight Consecutive Hours
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was available for at least eight consecutive hours per day on three specific days within a 31-day period. This deficiency was identified through a review of the Direct Care Staff Daily Reports, which showed no RN coverage on the dates of August 20, 21, and 22, 2024. The absence of RN coverage on these days placed residents at risk for delayed nursing assessments. The facility's administrator acknowledged the lack of RN coverage on the identified dates during an interview conducted on August 29, 2024.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to maintain proper storage temperatures for one of its medication storage refrigerators, as evidenced by temperature logs from August 2024. The logs indicated that the refrigerator on the East Hall exceeded the recommended temperature range of 36 to 46 degrees Fahrenheit on multiple occasions, reaching as high as 73 degrees Fahrenheit on August 21, 2024. This refrigerator contained flu vaccines and insulin, which require specific temperature conditions to maintain their efficacy. Staff 2, the Director of Nursing Services (DNS), acknowledged the temperature discrepancies during an observation on August 30, 2024. Additionally, the facility did not ensure proper labeling and security of treatment carts. On August 29, 2024, two open Tresiba insulin pens were found in the East Hall treatment cart without open dates, which was confirmed by an LPN. Furthermore, the same treatment cart was observed to be unlocked on two separate occasions, on August 26 and August 27, 2024, with residents and staff walking by. Staff 14, an LPN, admitted to leaving the cart unsecured both times, acknowledging that it should have been locked at all times to prevent unauthorized access to medications.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several deficiencies observed during the survey. Resident 19's room had an air conditioner unit that emitted a loud, high-pitched squeak, which was acknowledged by the facility's Administrator and Maintenance Director. Resident 6's bathroom light was burned out for about a week, despite being reported by a Nursing Assistant, and had not been fixed by the time of the survey. Additionally, Resident 27's room had a window with peeling paint and exposed particle board, and Resident 33's room had window trim pieces that were separated with exposed edges, both of which were acknowledged by the facility's staff. Resident 32's room and wheelchair were noted to have a strong odor of urine, which was acknowledged by multiple staff members, including CNAs, an LPN, and the Housekeeping staff. The resident was incontinent and wore multiple briefs and incontinent pads, contributing to the odor. Despite the night shift being responsible for cleaning wheelchairs, there was no documentation of the cleaning being done or of the resident refusing the cleaning. The facility's DNS and Corporate RN also acknowledged the persistent urine odor in the resident's room and wheelchair.
Failure to Inform Resident of Medication Risks and Benefits
Penalty
Summary
The facility failed to provide risk and benefit information for a psychotropic medication to a resident, which was necessary for making informed decisions about their care. The resident, admitted in July 2022 with diagnoses of depression, anxiety, and insomnia, was prescribed Trazodone for insomnia as per a physician's order dated January 24, 2024. Upon review of the resident's medical record, there was no documentation indicating that the risks and benefits of Trazodone were discussed with the resident. During an interview on August 27, 2024, the resident stated they did not recall discussing the risks and benefits of the medication with facility staff or signing a consent form. On August 29, 2024, a Licensed Practical Nurse (LPN) Unit Manager confirmed the absence of evidence that the risks and benefits were reviewed with the resident.
Failure to Document Advance Directives for Residents
Penalty
Summary
The facility failed to obtain and document information related to advance directives and health care decisions for three of four sampled residents. Resident 17, admitted in July 2016 with a diagnosis of depression, had no evidence in their clinical record of being provided with information on the right to formulate an advance directive. This was confirmed by the Director of Social Services. Resident 34, admitted in June 2024 with a diagnosis of diabetes, also had no documentation indicating that an advance directive was offered or reviewed with the resident or their family. The Director of Social Services was unable to recall or provide documentation of this process. Similarly, Resident 37, admitted in July 2022 with a diagnosis of diabetes, had no documentation of an advance directive being offered or reviewed, and the Director of Social Services could not provide evidence of this having occurred.
Deficiencies in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents, leading to deficiencies in oxygen administration and equipment maintenance. Resident 6, who was admitted in 2018 with chronic respiratory failure and hypoxia, had a physician order for weekly changes of the oxygen concentrator filter. However, observations on 8/27/24 revealed that the filters were dusty, indicating they had not been cleaned as required. Staff interviews confirmed that the responsibility for cleaning the filters was assigned to the evening nurse, but the task was not completed, as acknowledged by the Director of Nursing Services. Resident 10, admitted in 2014 with respiratory failure, was prescribed supplemental oxygen at 2 liters per minute to maintain oxygen levels above 90%. Observations from 8/26/24 to 8/29/24 showed the resident receiving oxygen at 3 liters per minute, contrary to the physician's order. Additionally, the oxygen tubing was not changed weekly, resulting in crusty debris on the nasal cannula. Staff confirmed the lack of documentation for tubing changes and acknowledged the absence of a facility policy for cleaning or changing oxygen tubing, contributing to the oversight.
Failure to Clean Glucometer Between Uses
Penalty
Summary
The facility failed to ensure proper cleaning and sanitization of a community use CBG glucometer between resident uses, which placed residents at risk for bloodborne illness. During an observation, an LPN was seen obtaining a CBG for a resident and then placing the glucometer back in the treatment cart without cleaning it. The LPN continued to pass medication and administer insulin to multiple residents without cleaning the glucometer. The LPN stated that she cleaned the glucometers at the beginning and end of her shift with purple wipes, but did not know where the wipes were located, and they were not on the treatment cart. The Director of Nursing Services stated that the expectation was for staff to clean glucometers with bleach wipes between every use. A Corporate RN confirmed that there were residents on the hall who required regular and PRN CBG checks.
Failure to Maintain Safe Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, specifically the walk-in refrigerator. On August 26, 2024, an observation revealed that the door handle to exit the refrigerator was missing. A dietary staff member stated that the handle had fallen off and was unsure of its whereabouts. The Dietary Manager acknowledged the issue and confirmed that the handle needed repair. A follow-up visit on August 28, 2024, showed that the door handle was still missing. On August 30, 2024, a dietitian mentioned that the staff needed to locate the handle and reattach it.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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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 Rehabilitation Of Eugene | 0.7 mi | ★★★★★ | 17 | 1 |
| Cascade Manor | 1 mi | ★★★★★ | 4 | 0 |
| South Hills Rehabilitation Center | 1.5 mi | ★★★★★ | 22 | 1 |
| Creekside Health And Rehabilitation Of Cascadia | 1.6 mi | ★★★★★ | 5 | 0 |
| Valley West Health Care Center | 2 mi | ★★★★★ | 0 | 0 |
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