Average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at La Grande Post Acute Rehab during CMS and state inspections, most recent first.
Unsanitary kitchen conditions and improper dish handling were observed when a dietary aide stored multiple wet utensils, pans, and steam table pans without drying them and put away a steam table pan that still had food debris after it had been through the dishwasher. The kitchen also had a sink with heavy calcification, damaged sticky countertops with exposed wood, stained pans, and dust and food debris on counters, floors, and around the steam table; the dietary manager and RD confirmed the areas were unclean and that wet dishes and calcified surfaces posed bacterial concerns.
Advance directives were not offered or discussed with two residents. One resident with ESRD was cognitively intact, and another resident with COPD had moderate cognitive impairment; both said they did not know what an advance directive was and wanted to complete one. The SSW Director said he did not offer or assist with advance directives, the RNCM said she did not do anything with them, and the Administrator acknowledged they were not being discussed with residents.
A resident with anxiety, PTSD, depression, and other psychiatric diagnoses did not have a PASRR level II referral after the diagnoses were added, even though the record showed behavioral concerns including verbal aggression, agitation, threats toward another resident, and trauma responses. Staff stated they did not understand that SMI-related diagnoses and behaviors could require a PASRR level II review, and the Administrator acknowledged a level II referral may have been needed.
A resident receiving hospice and comfort care had no documented urinary output across multiple shifts, with no documented bladder scan, catheter check, or replacement despite the absent output; the resident was later hospitalized for urinary retention and the catheter was found out of place with 1250 ml of urine drained. In a separate case, a resident with HTN and a stroke history missed several scheduled doses of lisinopril because a CMA believed it should be held for low systolic BP, even though the order had no hold parameters.
A resident with CKD and bladder neck obstruction had an indwelling urinary catheter ordered to be changed every 4 to 6 weeks and as needed. The record showed one catheter change by hospice, but no documentation of the next required change. The resident was later hospitalized with urinary retention, the catheter was found displaced, and hospital staff replaced it and drained 1250 ml of retained urine. An RNCM acknowledged the ordered catheter change schedule had not been followed.
A resident with ESRD and dialysis dependence missed ordered Zenpep and Sevelamer Carbonate doses on dialysis days because the meds were scheduled for noon while the resident left for dialysis at 11:00 AM. The record showed no attempt to adjust the med schedule, change dialysis timing, or send the meds with the resident, and dialysis clinic recommendations for fluid restriction and a Sevelamer Carbonate dose increase were not entered into active orders.
Failure to Provide Trauma-Informed Care: A resident with PTSD, depression, and anxiety had a documented trauma history, but the care plan lacked a trauma-specific focus and did not describe triggers, trauma responses, or interventions. Staff said they relied on the care plan and word of mouth, yet several did not recall seeing trauma-specific guidance, and one CNA reported nightmares and startle responses to loud, explosion-like noises.
Unnecessary Hypoglycemic Medication Administration: A resident with DM, CKD, and Alzheimer's/dementia received insulin glargine even when blood sugars were below the ordered hold parameter of 100. The MAR showed the insulin was given on multiple occasions with low blood sugar readings, and an LPN and RNCM confirmed the doses should not have been administered when the resident's blood sugars were that low.
Incomplete medication administration documentation: A resident with a history of stroke and HTN had multiple ordered meds and supplements repeatedly held or not given, with the MAR marked to see a progress note for details. Staff reported the meds were held for reasons such as tiredness, drooling, or choking, but no progress notes were found to explain the omissions, and the DNS confirmed the record lacked documentation for many missed doses.
Failure to Document Rationale for Ongoing Prophylactic Antibiotic Use: A resident with a hx of recurrent UTIs remained on chronic suppressive Bactrim therapy, and the prescriber continued the antibiotic without written justification after pharmacy requested a periodic risk-versus-benefit review. The NP stated he had not evaluated the ongoing need, the IP/RNCM was unsure why the antibiotic was ordered prophylactically and had not reviewed continuation, and the MAR showed the antibiotic was administered daily as ordered.
A resident with an indwelling urethral catheter had a physician order for an 18 Fr Foley catheter to be changed on a scheduled basis. On one shift, an RN changed the catheter but used a 20 Fr catheter because the ordered size was not available and did not notify the provider or facility leadership of this change. Later that evening, another RN was called due to the resident’s discomfort and, upon reassessment and lack of urine output despite fluid intake, discovered the catheter was a larger size than ordered, confirming that the catheter change had not followed the physician’s order or professional standards of care.
A resident with a known history of inappropriate touching was left unsupervised in the dining hall when a CNA briefly left to assist another resident. During this time, the resident touched another cognitively intact resident's genital area over clothing, despite verbal objections. The incident was witnessed by another resident, who called for help, and staff responded after hearing yelling. The lack of staff presence and supervision allowed the incident to occur.
A resident with a history of disinhibited sexual behaviors and a care plan requiring line-of-sight supervision was left unsupervised in the dining room by a CNA, resulting in the resident inappropriately touching another resident. Staff were aware of the resident's behavioral history and the need for supervision, but the care plan was not followed.
The facility failed to maintain hygienic conditions in its walk-in freezer and dry storage rooms, risking food-borne illness and cross-contamination. Observations included discarded food items on the floor, improperly stored food cartons, and unsealed food containers. The Dietary Manager acknowledged these issues, and the Administrator expected sanitary food storage practices.
A facility failed to reconcile controlled drugs accurately, as Morphine was found in a medication cart without a physician order or documentation in the accountability record. A CMA and a state surveyor discovered the issue, and the DNS confirmed the lapse in protocol for tracking and reconciling controlled substances.
A facility failed to secure a treatment cart and maintain proper medication refrigerator temperatures. The cart, left unlocked and unattended, contained various medications accessible to unauthorized individuals. The refrigerator lacked a thermometer, leading to temperature fluctuations that compromised drug efficacy. The pharmacist confirmed the need to destroy affected medications.
The facility failed to inform two residents of the risks and benefits of their prescribed psychotropic medications. One resident, with anxiety, was not informed about Duloxetine until months after administration began. Another resident, with Alzheimer's and bipolar disorder, was not informed about lurasidone and escitalopram. Staff confirmed these oversights.
A resident's wheelchair arm rests were found to be in disrepair, with torn and cracked surfaces exposing uncleanable cloth foam. The facility's maintenance log showed no reports of this issue, despite staff being instructed to document such concerns. Both the CNA and Maintenance Director confirmed the lack of documentation, and the Executive Director acknowledged the poor condition of the wheelchair arm rests.
A facility failed to follow bowel care physician orders for a resident, leading to multiple instances of unaddressed constipation. Despite the facility's Bowel Protocol Policy requiring action after three days without a bowel movement, the resident's records showed no PRN medications were administered during several periods of constipation. The resident, who was cognitively intact, reported experiencing long periods without a bowel movement, and the Divisional Director of Clinical Operations confirmed the protocol was not followed.
The facility did not have an antibiotic stewardship program in place, as confirmed by the Divisional Director of Clinical Operations. Four residents were receiving antibiotics without verified appropriate monitoring. Key staff, including the Infection Preventionist and Medical Director, were not conducting the required monthly reviews of antibiotic use.
Unsanitary Kitchen Surfaces and Wet Dish Storage
Penalty
Summary
Kitchen equipment and dishwashing practices were found to be unsanitary during observation of the facility’s dishwashing process and kitchen areas. A dietary aide put away multiple visibly wet serving utensils, cooking pans, and steam table pans with visible drips of water. The same staff member also rinsed a steam table pan that still had residual food scraps after it had been run through the dishwasher and stored it without rewashing it or allowing it to dry. The dietary aide confirmed the dishes had been put away wet and that the pan with food debris had not been rewashed. The dietary manager stated that dishes with food debris or visible dirt were expected to be rew washed and allowed to dry before storage, and the RD stated that putting dishes away wet posed a risk of bacteria development. The kitchen also had multiple sanitation concerns. The three-compartment sink had white calcification covering about 75% of its surface, including the sides and faucets, while ground meat was thawing in a container placed in the sink with cold water running into it. Countertops had missing sections exposing wood material with dark, scrapable buildup and were sticky to the touch. A slotted steam table pan had opaque white stains and small light brown stick-like material in one corner, and insulated plate warmer bases were stacked in it. Multiple counter surfaces were covered with dust and debris, and there were dust particles, food, and splatters on the floor, cabinet, and areas behind and around the steam table. The dietary manager confirmed the areas were unclean and stated the calcification and damaged countertops could not be adequately sanitized.
Advance directives not offered or discussed with residents
Penalty
Summary
The facility failed to have a process in place to ensure resident rights to execute an advance directive and to periodically follow up on residents’ preferences for 2 of 2 sampled residents reviewed for advance directives. The facility’s policy dated 1/2025 stated that during admission, if a resident did not have an advance directive and wished to formulate one, assistance would be provided using state-specific forms, and that discussion and documentation of future health care choices, including review of the advance directive, would occur during the initial comprehensive assessment and care plan process, quarterly, annually, with significant changes in condition, or at the resident’s request. One resident was admitted in 2/2026 with end stage renal disease and was cognitively intact on the 5-day Medicare MDS. The clinical record contained no evidence that an advance directive was discussed or offered, and the resident stated not knowing what an advance directive was and being uncertain whether staff had ever talked about one; the resident also expressed interest in completing one. Another resident, admitted in 8/2023 with COPD and identified on the quarterly MDS as having moderate cognitive impairment, also stated not knowing what an advance directive was and being uncertain whether staff had ever talked about one, while expressing a desire to complete one. Staff interviews showed the Social Services Director did not offer, explain, or assist residents with advance directives, the RNCM stated she did not do anything with advance directives and only encouraged residents to discuss them with physicians, and the Administrator acknowledged advance directives were not being offered or discussed with residents.
Failure to Refer Resident With SMI-Related Diagnoses for PASRR Level II Review
Penalty
Summary
The facility failed to ensure that a resident with serious mental illness-related diagnoses had a PASRR level II referral after new psychiatric diagnoses were added. The resident was admitted with anxiety, later had PTSD added to the record, and the annual MDS indicated active diagnoses of depression, anxiety, and PTSD while PASRR level II screening was marked as not needed. Review of the clinical record showed a PASRR level I screening had been completed before a readmission and was marked "no SMI," but after PTSD, major depressive disorder, and adjustment disorder were documented, no evidence was found that a PASRR level II referral was submitted. The resident also had documented behavioral concerns. A progress note described a verbal altercation in which the resident chased another resident down the hallway and threatened to harm that resident after an interaction. The care plan identified behaviors requiring intervention and psychotropic medication use, including accusing others, expressing frustration and anger, agitation, and cursing others. Staff described ongoing verbal aggression, agitation with change, targeting timid individuals, and trauma responses such as loud-noise sensitivity and nightmares about war. The Social Services Director stated he was unaware that SMI diagnoses required PASRR level II referrals, and the Administrator stated that if the PASRR level I screen did not indicate SMI, a level II screen was not needed, though he acknowledged a level II referral may have been needed given the resident's PTSD and behaviors.
Failure to Provide Ordered Care and Medication Administration
Penalty
Summary
The facility failed to provide care and services related to hospice and comfort care for a resident with bladder neck obstruction, dementia, palliative care, and an indwelling urinary catheter. On 5/10/26 and 5/11/26, the resident had no documented urinary output across multiple shifts, and there was no documentation of any assessment or intervention such as a bladder scan, catheter evaluation, or catheter replacement despite the absence of output. The resident was later sent to the hospital at the family’s request and was admitted with urinary retention; hospital records stated the catheter was found out of place and 1250 ml of concentrated, odorous urine was drained from the bladder before the catheter was removed and replaced. Witnesses and staff described the events surrounding the resident’s condition. A family member stated they repeatedly observed no urine in the collection bag, the resident appeared uncomfortable, vomiting had occurred, hospice was contacted, and the resident continued to appear uncomfortable until transport was requested. A CNA stated little to no urinary output was observed on the day shift but was not documented or reported, while another CNA stated little to no output was observed on the night shift and was reported to the charge nurse and documented. A hospice RN stated they saw the resident for vomiting and observed scant urine in the collection bag but did not examine or palpate the bladder. The facility also failed to follow a physician order for another resident with a history of stroke, right-sided weakness/paralysis, and hypertension. The resident’s order directed lisinopril in the morning, but the medication was not administered on several dates in June and July 2026. A CMA stated she withheld the medication because she believed it should be held when systolic blood pressure was below 100, even though the order contained no such instruction. An RNCM reviewed the order and confirmed there were no hold parameters, and stated the medication should have been administered as ordered.
Failure to Follow Ordered Indwelling Catheter Change Schedule
Penalty
Summary
Failure to provide adequate catheter care was identified for one resident with an indwelling urinary catheter. The resident was admitted with diagnoses including chronic kidney disease and bladder neck obstruction, and the care plan and physician orders directed that the catheter be replaced every four to six weeks and as needed. The medical record showed the catheter was changed during a hospice visit, but there was no documentation that it was changed again after that date, even though it was due no later than 5/6/26. On 5/11/26, the resident was hospitalized with urinary retention, and the indwelling catheter was found to be displaced and was replaced by hospital staff; 1250 ml of retained urine was drained from the bladder. An RNCM stated that nursing staff were expected to follow physician orders and acknowledged that the catheter change frequency ordered for the resident had not been followed.
Missed dialysis-related medications and unaddressed dialysis recommendations
Penalty
Summary
The facility failed to ensure dialysis-related medication administration and dialysis recommendations were followed for a resident with ESRD and dependence on renal dialysis. The resident was admitted in 3/2026, was cognitively intact per the 5/18/26 5-Day MDS, and received dialysis treatments three days per week. Physician orders included leaving the facility at 11:00 AM on Monday, Wednesday, and Friday for dialysis, along with Zenpep and Sevelamer Carbonate ordered three times daily with meals. The MAR showed the Zenpep and Sevelamer Carbonate were not administered on multiple days because the resident was out of the facility for dialysis when the medications were scheduled for 12:00 PM. The clinical record contained no evidence that the facility attempted to adjust the medication schedule, alter dialysis timing, or send the medications with the resident so they could be administered as ordered. Staff stated the medications were not given on dialysis days because they were scheduled for noon and the resident left at 11:00 AM, and that no order had been obtained to hold the medications. The record also showed dialysis recommendations were not followed up on, including a fluid restriction of 2 liters or less from the dialysis transfer form, a later recommendation to maintain fluid restriction at 2000 cc per day, and a request from the dialysis clinic to increase Sevelamer Carbonate and add a PRN dose with a large snack. No active orders for fluid restriction or the requested Sevelamer Carbonate change were present, and staff confirmed these dialysis clinic recommendations were not entered into the resident's orders.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to ensure that a resident with a history of trauma received trauma-informed care. The resident was admitted with anxiety, later had PTSD added to the diagnoses, and the annual MDS indicated the resident was cognitively intact with active diagnoses of depression, anxiety, and PTSD. The resident’s records also showed a history of working as a paramedic, working in an emergency department, and serving as a military veteran. A trauma informed care form documented that the resident reported abuse by a stepparent and a friend who threw things around, and a later form noted the resident did not want to talk about the trauma with Social Services. The care plan did not include an observed trauma-specific focus. PTSD was listed as a contributing diagnosis for risk areas including nutrition/hydration deficits, ADL self-care performance deficits, and impaired psychosocial well-being, but the record did not describe the trauma response, how PTSD affected those care areas, or interventions to prevent or address trauma responses. Staff interviews showed CNA staff relied on the care plan and word of mouth to identify trauma-related needs, but several staff did not recall seeing trauma-specific information in the care plan. One CNA reported the resident had nightmares and became startled by loud, explosion-like noises, and another staff member stated he was unaware of those reported triggers and had not added a trauma care plan, acknowledging he should have care planned the resident’s PTSD diagnosis and desire not to discuss the trauma.
Unnecessary Hypoglycemic Medication Administration
Penalty
Summary
The facility failed to ensure a resident was free from unnecessary hypoglycemic medications when insulin glargine was administered despite blood sugar readings below the ordered hold parameter. The resident was admitted with diagnoses including diabetes, chronic kidney disease, and Alzheimer's/dementia. Physician orders dated 5/22/26 directed that insulin glargine be given once daily and held if blood sugar readings were less than 100. The resident's MAR for 7/1/26 through 7/20/26 showed insulin glargine was given on 7/1/26 with a blood sugar of 97, on 7/8/26 with a blood sugar of 89, and on 7/16/26 with a blood sugar of 86. An LPN reviewed the MAR and confirmed the insulin was administered when blood sugars were less than 100 on 7/8/26 and 7/16/26, and the RNCM stated the resident's blood sugars were running low and the resident should not have received insulin glargine on 7/1/26, 7/8/26, and 7/16/26 when the blood sugars were that low.
Incomplete Medication Administration Documentation
Penalty
Summary
Resident 17, who was admitted in 3/2024 with diagnoses including stroke with right side weakness/paralysis and hypertension, had physician orders for multiple daily medications and supplements, including cholecalciferol, cranberry oral tablet, spironolactone, ascorbic acid, multivitamins, senna, and phenazopyridine. Review of the 6/1/26 through 7/20/26 MAR showed that these medications were not consistently administered, and the MAR was marked with a 5 indicating the medications were held and to see a progress note for details. For the dates reviewed, medications were not given and no progress notes were found to explain the omissions for cholecalciferol, cranberry oral tablet, spironolactone, ascorbic acid, multivitamins, senna, and phenazopyridine on multiple days. Staff 20 stated she held medications for reasons such as the resident being tired, medications drooling from the resident's mouth, or choking on medications, and said she communicated these holds to the charge nurse. Staff 19 confirmed she was informed when medications were not administered and that no progress notes were written to explain the omissions. The DNS also reviewed the record and confirmed there were many days when medications were not administered and no progress note documented the reason.
Failure to Document Rationale for Ongoing Prophylactic Antibiotic Use
Penalty
Summary
The facility failed to implement antibiotic stewardship practices for one resident who was reviewed for antibiotic use. The facility’s Antibiotic Stewardship Policy dated 3/2018 instructed staff to collaborate with providers regarding the resident’s clinical status and current treatment and to document the clinical rationale supporting antibiotic use. Resident 5 was readmitted in 1/2025 with diagnoses including UTI, and the 5/24/26 Annual MDS indicated the resident was cognitively intact and taking an antibiotic. Hospital clinical records dated 1/6/25 showed the resident was discharged on low-dose chronic suppressive therapy with Bactrim daily because of four UTIs in four months. A pharmacy recommendation dated 4/27/26 stated the pharmacist advised the prescriber that periodic assessment of prophylactic antimicrobial therapy was needed to minimize potential resistance and asked whether the antibiotic needed to continue indefinitely and for a brief risk-versus-benefit assessment to justify continuation. The prescriber marked yes to continuing the antibiotic but did not provide written justification. Review of the 7/2026 physician orders showed Bactrim DS 800-160 mg, 0.5 tablet daily, and the MAR showed it was administered daily as ordered. Staff 14 stated he was not the original prescriber and continued the medication because the hospital felt it was necessary, but he had not evaluated the ongoing use or documented justification. Staff 3 stated she was unsure why the antibiotic was ordered prophylactically and had not reviewed the need to continue daily Bactrim. Staff 2 stated she thought Staff 14 had provided justification, but no additional information was provided.
Incorrect Foley Catheter Size Used and Physician Order Not Followed
Penalty
Summary
The deficiency involves failure to provide catheter care and treatment in accordance with professional standards for a resident with an indwelling urethral catheter. The resident was admitted with an order for an 18 French Foley catheter to be changed every four weeks. On one evening, a registered nurse documented changing the resident’s Foley catheter, and later that same evening, the resident requested that another registered nurse flush the catheter. When the second nurse rechecked the resident a couple of hours later, there was no urine output despite the resident having consumed over 400 cc of water. Upon assessment, the second nurse observed that the catheter in place was a size 20 French, not the ordered 18 French. The second nurse later stated that when she attempted to adjust the catheter due to the resident’s discomfort, she noticed the catheter was larger than ordered. The nurse who performed the catheter change acknowledged she had used a 20 French catheter because she could not find an 18 French in the facility and did not notify anyone at the facility or the provider about this deviation from the physician’s order. The Director of Nursing Services confirmed that physician orders should be followed and acknowledged that the wrong catheter size had been used for this resident.
Failure to Prevent Sexual Abuse Due to Lack of Supervision
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse when one resident was observed touching another resident's genital area over clothing in the dining hall. Both residents involved were cognitively intact, as indicated by their BIMS scores. The incident occurred when a CNA, who was aware of the perpetrating resident's history of inappropriate touching, left the dining room briefly to assist another resident. During this absence, the resident with a history of inappropriate behavior approached and touched the other resident, despite the latter's verbal objections. The incident was witnessed by another resident, who called for help, prompting staff to intervene. At the time of the incident, there were no staff present in the dining room, leaving the residents unsupervised. Staff interviews confirmed that the CNA assigned to supervise had left the area, and other staff only became aware of the situation after hearing yelling. The lack of supervision allowed the incident to occur, and the facility's failure to ensure continuous monitoring of a resident with known behavioral risks directly led to the deficiency.
Failure to Implement Supervision Care Plan for Resident with Inappropriate Sexual Behaviors
Penalty
Summary
The facility failed to implement the care plan for a resident with a history of disinhibited sexual behaviors, specifically related to inappropriate touching of other residents. The resident, who was cognitively intact and had a care plan revised to address these behaviors, was to be kept within line of sight of staff and not allowed to dine with residents of the opposite gender. Despite these interventions, a certified nursing assistant (CNA) left the resident unsupervised in the dining room while attending to another resident, during which time the resident in question inappropriately touched another resident. Staff interviews confirmed awareness of the resident's behavioral history and the lapse in supervision that allowed the incident to occur.
Improper Food Storage and Hygiene in Kitchen
Penalty
Summary
The facility failed to maintain hygienic conditions in its walk-in freezer and dry storage rooms, which placed residents at risk of food-borne illness and cross-contamination. During an initial tour of the kitchen, surveyors observed several issues in the walk-in freezer, including a discarded frozen snack cup and a partial hamburger patty on the floor, a cardboard case of chocolate health shake cartons stored on the floor, and discarded plastic wrappers scattered under and between shelving units. Additionally, a plastic-lined cardboard case of frozen peas and chopped carrots was found with the lid unsealed and open. In the dry-storage room, a plastic-lined cardboard box of parboiled rice was also found with the lid unsealed and open. The Dietary Manager acknowledged that the food in the freezer was not stored properly and that the freezer was not cleaned appropriately. During a follow-up tour, a cardboard box of saltine crackers was observed stored on the floor of the food storage closet adjacent to the rear kitchen door. The Dietary Manager confirmed that no food items should be stored on the floor, even if they were in boxes. The facility's Food Storage policy requires that food storage areas be kept clean at all times, dry bulk foods be stored in seamless plastic or metal bins with tight-fitting lids, and items in the freezer be kept on shelving above the floor. The Administrator stated that he expected food to be stored in a sanitary manner with residents' safety in mind.
Failure to Reconcile Controlled Drugs
Penalty
Summary
The facility failed to ensure accurate reconciliation and accountability for controlled drugs, specifically Morphine, in one of the medication carts reviewed. During an inspection, it was discovered that the narcotic compartment of the medication cart contained four bubble pack cards of Morphine, each with 60 half tablets, labeled with a resident's name. However, there was no physician order for Morphine for this resident, and the medication was not documented in the facility's accountability record. This oversight was identified during a review by a Certified Medication Aide (CMA) and a state surveyor. Staff 5, the CMA, acknowledged the absence of documentation and reported the issue to the Director of Nursing Services (DNS) and other agency nurses, awaiting further instructions. Staff 2, the DNS, confirmed that the proper procedure was to document controlled drugs immediately upon receipt and to reconcile them at each shift change. However, the DNS was unaware of the Morphine's presence in the narcotic compartment until the surveyor's review, indicating a lapse in the facility's protocol for tracking and reconciling controlled substances.
Medication Security and Storage Deficiencies
Penalty
Summary
The facility failed to ensure the security and proper storage of drugs and biologicals, as evidenced by an unlocked and unattended treatment cart and improper temperature control in the medication refrigerator. On one occasion, a treatment cart located near the nursing station was left unlocked and unattended by two nursing students, making it accessible to unauthorized staff and residents. The cart contained various medications, including insulin and medicated creams, which should have been secured when not in use. The facility's policy required that treatment carts be locked when unattended, a standard that was not adhered to in this instance. Additionally, the medication refrigerator was found to be improperly monitored and maintained, with no thermometer inside to track temperatures. A CMA was observed using a thermometer from an adjacent empty refrigerator to check the temperature, which was found to be significantly below the recommended range. The refrigerator's temperature fluctuated between 20 degrees F and 50 degrees F, compromising the efficacy of the stored medications, including insulin, vaccines, and other critical drugs. The facility's policy and CDC guidelines specify that medications requiring refrigeration should be stored between 36 degrees F and 46 degrees F, a standard that was not met. The pharmacist confirmed that the fluctuating and potentially freezing temperatures compromised the refrigerated drugs, necessitating their removal and destruction. The facility's failure to maintain proper storage conditions for medications and biologicals placed residents at risk for receiving ineffective treatments. The administrator and divisional director of clinical operations were informed of these findings, acknowledging the deficiencies in medication security and storage practices.
Failure to Inform Residents of Psychotropic Medication Risks and Benefits
Penalty
Summary
The facility failed to inform two residents of the risks and benefits associated with their prescribed psychotropic medications. Resident 10, admitted in May 2024 with a diagnosis of anxiety, was prescribed Duloxetine, an antianxiety medication, but was not informed of its risks and benefits until October 2024, despite having been administered the medication since May 2024. Staff 3, a Registered Nurse and Divisional Director of Clinical Operations, confirmed this oversight. Similarly, Resident 7, who was admitted in October 2021 with Alzheimer's disease and bipolar disorder, was prescribed lurasidone, an antipsychotic, and escitalopram, an antidepressant, in February 2025. However, there was no documentation indicating that Resident 7 was informed of the risks and benefits of these medications. Staff 2, the Director of Nursing Services, acknowledged that Resident 7 was not informed in advance.
Failure to Maintain Safe and Clean Wheelchair Arm Rests
Penalty
Summary
The facility failed to provide a safe and clean environment for a resident by not maintaining the resident's wheelchair arm rests in proper condition. On February 10, 2025, it was observed that the left arm rest of the resident's wheelchair was torn and cracked, exposing uncleanable cloth foam. This condition was not reported in the facility's maintenance log, which covered the period from December 5, 2024, to February 10, 2025. Staff members, including a CNA and the Maintenance Director, confirmed that the procedure was to document such issues in the maintenance log, but no reports were made regarding the resident's wheelchair. The Executive Director also confirmed the poor condition of the wheelchair arm rests and acknowledged the expectation for residents to have safe and cleanable wheelchairs.
Failure to Administer Bowel Care Medications as Ordered
Penalty
Summary
The facility failed to adhere to the bowel care physician orders for a resident who was admitted with a diagnosis including pain. The facility's Bowel Protocol Policy, updated in 2018, required that each resident be placed on a daily bowel monitoring program, with licensed nurses reviewing the bowel monitoring daily. If a resident did not have a bowel movement for three days, the nurse was to administer the physician-ordered bowel program or the facility-specific PRN medication bowel program. However, the resident's bowel records from January 10 to January 31 revealed multiple instances where the resident did not have a bowel movement for several consecutive days, specifically on the 16th, 17th, 18th, 19th, 20th, 24th, 25th, 26th, 27th, and 28th. Despite the absence of bowel movements on these dates, the Medication Administration Record (MAR) showed that no PRN bowel care medications for constipation were administered. The resident, who was cognitively intact, expressed experiencing long periods without a bowel movement and noted that staff had not addressed the constipation. The Divisional Director of Clinical Operations confirmed that the PRN medications were not administered according to the facility protocol for bowel care, acknowledging that the protocol should have been followed.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program, which is a critical component of infection control. During the review, it was found that there was no evidence of such a program in place. Staff 3, the Divisional Director of Clinical Operations, was interviewed and confirmed the absence of an antibiotic stewardship program. Staff 3 also mentioned that four current residents were receiving antibiotics, but there was no verification of appropriate monitoring for the continued use of these medications. Furthermore, Staff 3 indicated that key personnel, including the Infection Preventionist, Pharmacist, Executive Director, and Medical Director, were supposed to be involved in a monthly review of antibiotic use, but these meetings had not been conducted.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the citations issued around you in the last 12 months — including the 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for La Grande Post Acute Rehab.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.