Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pilot Butte Rehabilitation Center during CMS and state inspections, most recent first.
A resident with traumatic brain injury, brain damage, adjustment disorder, and cognitive impairment repeatedly used profanity, homophobic slurs, and threats toward other residents in common areas, including the dining room. Multiple residents reported feeling uncomfortable, threatened, upset, and unsafe, and staff witnesses confirmed the abusive outbursts occurred in front of other residents.
Failure to Report Allegations of Verbal Abuse: The facility did not report multiple allegations of verbal abuse involving one resident toward several other residents to the State Survey Agency. Grievance forms and staff statements documented homophobic slurs, foul language, and threats of physical assault, while the Administrator stated she did not believe the allegations rose to the level of reportable abuse.
Failure to investigate verbal abuse allegations involving multiple residents. A resident with depression and muscle wasting, a resident with stroke, and two other residents had grievance forms and behavior notes documenting another resident using derogatory names, making threats, and yelling homophobic slurs. The Social Services Director stated no formal investigation was completed, and the Administrator said interviews and documentation should have been done, but no thorough investigation was documented.
Misappropriation of resident narcotic medications: An LPN repeatedly administered and disposed of controlled medications for multiple residents, and the facility later found missing narcotic log pages and unaccounted-for medication cards for opioid and anxiolytic orders. Residents with chronic pain, phantom limb pain, and anxiety had narcotics documented as given, but the facility could not account for the medications in the narcotic records and determined misappropriation had occurred.
A resident with cognitive impairment and prior burn injuries was discharged to homelessness/vehicle living without documented completion of the stated home health referral, despite notes that the discharge plan was unsafe and that the resident needed PT/OT/ST. The resident later sustained serious fractures after being found on the ground outside the vehicle. In a later discharge episode, the resident was documented as confused, a fall risk, and needing assistance with ADLs and neck brace/med management, yet left before neurosurgical clearance and there was no documented AMA signature or completed home health referral.
Unsafe Water Temperatures on Falls Hall: Multiple resident sinks on Falls Hall were observed with water temperatures above the facility’s stated limit of 120 degrees F, including readings of 123.3, 124.7, 129.4, and 132.1 degrees F. The Maintenance Director said he checked temperatures weekly, usually in the morning, and the Administrator stated audits should vary by time of day to identify temperature changes. Staff reported residents usually said the water was not warm enough, while some residents said they liked the hot water or had no concerns.
Improper Hand Hygiene and Contaminated Surface Contact in Kitchen: Kitchen staff failed to maintain proper hand hygiene and sanitary practices during food prep and plating. A Dietary Manager handled meal tickets, clipboards, bread, raw foods, and cooked meat with gloved hands without washing or changing gloves, and also used a cutting board after touching meal tickets identified as contaminated surfaces. Another staff member removed condiments with bare hands and then touched clean dishes without washing hands or donning gloves. Leadership later acknowledged the improper hand hygiene.
Staff did not follow isolation and EBP PPE requirements for two residents. One resident on Contact Isolation was followed into the hall while the staff member still wore a gown after removing gloves, and another resident with an indwelling catheter and infection risk was transferred with a mechanical lift and later had catheter care performed while staff wore gloves only, despite posted directions and the care plan requiring gown and glove use for high-contact care.
Failure to obtain and document informed consent for psychotropic meds affected two residents. One resident with depression and bipolar disorder received daily Depakote without evidence that the risks and benefits were discussed. Another resident with dementia and a responsible party received Depakote Sprinkles for agitation and mood before consent from the resident representative was found in the chart; an RN stated she did not know consent was needed before administration.
Failure to provide a written bed hold notice, including reserved bed hold payment information, and to notify the Ombudsman when a resident with kidney failure was transferred to the hospital. Record review found no evidence that the resident or representative received the required bed hold notification, and staff verified the Ombudsman was not notified.
Failure to follow MD orders affected three residents. One resident with heart disease had a critically low potassium level, refused ER transport because of cost, and was later hospitalized with NSTEMI, with no documentation that the MD was told the order was not carried out or that the resident was monitored after refusal. Another resident on dialysis missed multiple ordered meds on several occasions, and staff said meds were often not given on dialysis days. A third resident with dementia did not receive ordered bisacodyl after two days without a BM, while staff used a three-day bowel protocol instead of the MD order.
Failure to Protect Residents from Neglect and Abuse: A resident with quadriplegia and ALS was not repositioned during the night shift and reported that a CNA turned off the call light, did not provide care, and did not offer hydration or toileting. In a separate incident, another resident reported that a CNA was rough during repositioning, ignored complaints of pain, and the facility later acknowledged the resident was abused.
The facility failed to timely report allegations of abuse and neglect involving multiple residents. A resident with a pelvic fracture alleged an RN and CNA gave care against the resident’s will, and another resident reported verbal and physical abuse by a CNA; in both cases, staff learned of the allegations but the reports were not made within the expected timeframe. A third resident with quadriplegia and ALS was involved in a neglect allegation after staff were observed turning off a call light without providing care, and the concern was reported to the DNS after the event.
A resident with severe cognitive impairment and high elopement risk left the facility unsupervised, walking 1.8 miles before being found by police. The facility failed to follow the care plan, which included 15-minute checks and supervision, leading to the resident's elopement.
A resident with ALS reported discomfort due to cold temperatures in her/his room and hall, which were set at 68 degrees. Despite complaints to management and nursing staff, no action was taken. CNAs confirmed the cold conditions and resident complaints. The Maintenance Director tested temperatures but did not document results, while the DNS acknowledged the thermostat should be set between 71 and 81 degrees for comfort.
The facility failed to provide therapeutic diets to three residents, including those with diabetes and malnutrition. A resident with end-stage kidney disease did not receive a diabetic diet as prescribed, while another resident with malnutrition did not receive nutritionally enhanced meals. Additionally, a diabetic resident on a low carbohydrate diet received extra carbohydrates and did not receive the fruit they ordered. The Dietary Manager acknowledged the lack of adherence to prescribed dietary requirements.
The facility failed to provide meals that were palatable, attractive, and at an appetizing temperature, affecting three residents. A resident with cancer reported cold and chewy food, while another with malnutrition received a meal with raw hamburger. A third resident with a surgical infection experienced cold food upon delivery. Test trays confirmed these issues, and staff acknowledged the deficiencies.
The facility failed to ensure beard restraints were worn during meal preparation, as observed in a kitchen review for sanitary food practices. Despite a policy requiring beards to be covered, the Dietary Manager and a Cook were seen preparing food without beard restraints. The Dietary Manager was unaware of this requirement, and the RD later confirmed the necessity of beard coverings.
A facility failed to obtain informed consent for a resident's medication, buspirone, which was incorrectly listed as an antidepressant instead of an anxiolytic. The resident, with dementia and agitation, had a physician's order for buspirone, but the consent form did not accurately reflect the medication's classification. The DNS confirmed the error, acknowledging the lack of informed consent.
A resident with a history of stroke and anxiety, who was cognitively intact, consistently refused showers because they were scheduled at night, contrary to their preference. Despite requests for a different bathing schedule, no changes were made, and an investigation into the refusals was not initiated. Staff acknowledged the resident should have been informed about alternative shower schedules.
The facility failed to provide advance directive information to three residents, despite care conference forms indicating the presence of such directives. One resident with impaired cognition and two cognitively intact residents reported not receiving any information about advance directives. The Social Service Director confirmed the absence of documentation in their clinical records.
A facility failed to issue an Advanced Beneficiary Notice (ABN) to a resident who transitioned from a Medicare skilled stay to Medicaid coverage. The resident, admitted with respiratory failure, had a Medicare stay that ended, after which they continued under Medicaid. A review revealed no ABN was provided, a lapse acknowledged by a Regional Nurse Consultant.
Three residents reported abuse by a former agency CNA, Staff 23, who provided rough and inappropriate care. Despite being cognitively intact, the residents experienced verbal and physical abuse, which was confirmed by the facility's investigation.
The facility failed to update care plans for two residents, one with discontinued anticoagulant therapy and another started on Ativan. The care plans lacked necessary revisions to reflect medication changes and specific interventions, as confirmed by the Resident Care Manager.
The facility failed to follow physician orders and care plans for two residents, leading to unmet care needs. One resident missed eight doses of prescribed medication for restless leg syndrome, while another resident's care plan to avoid contact with a specific individual was not enforced, resulting in an uncomfortable encounter in the dining room. The issues were acknowledged by the facility's administration.
A resident with a history of stroke and cognitive intactness requested a hearing doctor appointment, which was not scheduled by the facility. Despite being hard of hearing and recommended for hearing aids months prior, the resident did not receive the necessary audiology exam. The Social Service Director and RN Resident Care Manager acknowledged the oversight, and the resident's son was contacted to arrange the appointment.
The facility failed to accurately assess and follow physician orders for pressure ulcer care for two residents. One resident's heels were not floated as ordered, and another resident's sacral wound was inaccurately assessed and documented, leading to a Stage 4 pressure ulcer. Staff interviews revealed communication and documentation lapses.
A resident with moderate cognitive impairment and a history of stroke was identified as a moderate risk for elopement, yet the facility failed to implement an elopement care plan. Observations showed the resident moving freely throughout the facility, and staff confirmed the oversight.
A facility failed to monitor a dialysis access site and provide appropriate dietary accommodations for a resident with end-stage kidney disease. Despite a care plan requiring daily assessment of the dialysis shunt and specific dietary needs, records showed no post-dialysis monitoring, and the resident reported not receiving meals during dialysis. Staff acknowledged the oversight, but the Dietary Manager was unaware of the required meal accommodations.
A facility failed to assist a resident with discharge planning, leading to confusion and anxiety. The resident, with moderate cognitive issues, wanted to return home, but the facility did not specify what was needed for a safe discharge. The family requested a home evaluation and was informed of the need for 24/7 support, but the facility did not provide details on care or equipment. The resident expressed confusion, and the family and local unit reported a lack of communication and assistance from the facility.
A facility failed to provide non-pharmacological interventions before administering PRN Ativan to a resident with dementia, risking sedation. The resident's care plan noted a risk for Ativan side effects, yet the medication was given 53 times in May 2024, often with oxycodone, without clear documentation of anxiety symptoms or interventions. Staff interviews revealed inconsistent documentation and intervention practices.
A resident with high blood pressure and end-stage kidney disease did not receive their prescribed hypertensive medication, metoprolol succinate, after returning from the hospital. The medication was last given before the resident's hospital discharge, and upon return, the orders were not double-checked, leading to a lapse in administration.
Two residents with diabetes did not receive meals according to their preferences and dietary needs. One resident frequently received incorrect meals, while another received carbohydrates despite being on a controlled carbohydrate diet. The Dietary Manager admitted there was no documentation on portion sizes or dietary restrictions, leading to unmet needs.
A resident with chronic respiratory failure was not offered the Prevnar 20 vaccine, despite being eligible. This oversight was confirmed by the DNS during an interview.
A facility failed to report an unwitnessed fall with serious bodily injury to the State Agency. A resident with a history of falls and dementia was found with injuries including a fractured elbow requiring surgery. Despite the severity, no Facility Reported Incident was submitted.
The facility failed to thoroughly investigate an unwitnessed fall with a major injury involving a resident with a history of falls. Critical details were missing from the investigation, such as witness statements, reasons for the resident's actions, and whether care interventions were followed. The incident was also not reported to the state agency as required.
The facility failed to ensure a safe environment for a resident with a neck fracture and history of falls. The resident was found on the bathroom floor with a detached toilet, which had been left unsecured by the Maintenance Director without proper signage or staff notification.
Failure to Protect Residents from Verbal Abuse
Penalty
Summary
The facility failed to protect residents from verbal abuse by another resident. Interviews and record review showed that one resident with traumatic brain injury, brain damage, adjustment disorder, and moderate cognitive impairment repeatedly directed profanity, homophobic slurs, and threats toward other residents in shared areas of the facility. The affected residents included one who was cognitively intact, another who was cognitively intact, and a third whose MDS later showed severe cognitive impairment. A grievance documented that the resident with behavioral symptoms had called another resident derogatory names and made threats. The resident’s care plan identified a risk for verbal outbursts of yelling and cursing when redirected or educated and noted the resident should be approached calmly and kept in a supervised area when out of bed. Despite this, staff interviews described repeated episodes in which the resident yelled, cursed, and used offensive language in public spaces, including the dining room, where multiple residents were present. The affected residents reported feeling uncomfortable, threatened, upset, and unsafe because of the verbal abuse. One resident stated the cursing occurred about once a month and made the resident uncomfortable. Another stated the resident had threatened to attack and used derogatory statements that brought up bad memories. A third resident stated the resident had been verbally abusive and had said, "I'm going to knock your ass," while staff witnesses confirmed the resident had yelled homophobic slurs at residents in the dining room and that one resident was tearful after the incident.
Failure to Report Allegations of Verbal Abuse
Penalty
Summary
The facility failed to report allegations of verbal abuse to the State Survey Agency for 4 of 5 sampled residents reviewed for verbal abuse. Resident 15, admitted with diagnoses including depression and muscle wasting, had a grievance form dated 2/3/26 documenting that Resident 17 verbally abused them by calling them "pussy" and "faggots" and threatening physical assault. Resident 16, admitted with diagnoses including stroke, also had a 2/3/26 grievance form documenting that Resident 17 verbally abused them using the same language. For both residents, there was no documented evidence that the allegations were reported to the State Survey Agency, and the Administrator stated on 6/24/26 that she did not feel the allegations rose to the level of reportable abuse. Resident 18, admitted with diagnoses including stroke, had a grievance form dated 3/13/26 documenting discomfort with Resident 17's actions, including yelling curse words and vile names at residents and staff. A behavior note from the same date documented that Resident 17 was upset about the dining room seating arrangement, screamed homophobic slurs at other residents, and refused to calm down. Resident 19, admitted with diagnoses including depression and stroke, had a grievance form dated 3/13/26 documenting that Staff 43 had been advocating for them due to verbal abuse by Resident 17, and Staff 43 later stated that Resident 17 called Resident 19 a "gay little faggot." There was no documented evidence that the allegations involving Residents 18 and 19 were reported to the State Survey Agency, and the Administrator again stated she did not feel the allegations rose to the level of reportable abuse.
Failure to Investigate Verbal Abuse Allegations
Penalty
Summary
The facility failed to investigate allegations of verbal abuse involving Resident 17 and four residents. Resident 15, admitted in 12/2024 with diagnoses including depression and muscle wasting, had a grievance form documenting that Resident 17 called Resident 15 derogatory names and made threats. The form noted Resident 17 denied the allegations and had been advised to request a staff member when upset, but there was no documented evidence of a thorough investigation. The Social Services Director stated no formal investigation was completed, and the Administrator stated interviews with staff and residents should have been conducted and documented, but provided no additional evidence that this occurred. Resident 16, admitted in 8/2022 with a stroke diagnosis, had a grievance form documenting the same verbal abuse allegations by Resident 17, with no documented thorough investigation and no formal investigation completed. Resident 18, admitted in 9/2022 with a stroke diagnosis, had a grievance form stating Resident 18 was extremely uncomfortable due to Resident 17 yelling curse words and vile names at residents and staff; a behavior note also documented Resident 17 screaming homophobic slurs and refusing to calm down. Resident 19, admitted in 7/2025 with diagnoses including depression and stroke, had grievance forms and witness statements documenting that Resident 17 called Resident 19 a derogatory name and was screaming and yelling over dining room seating. Staff 43 confirmed completing the grievance for Resident 19 and stated Resident 19 had been tearful, but there was no documented evidence of a thorough investigation for either Resident 18 or Resident 19.
Misappropriation of resident narcotic medications
Penalty
Summary
The facility failed to ensure residents were free from misappropriation of property for 3 of 3 sampled residents reviewed for misappropriation. Resident 8 was admitted with diagnoses including complex pain syndrome and anxiety disorder and had orders for lorazepam as needed for anxiety and oxycodone as needed for chronic pain. Facility narcotic logs showed the medications were administered repeatedly over the review period, with Staff 3 (LPN) administering most of the doses. The facility later identified that medication disposal documentation was problematic and that it could not account for medications within the narcotic log. Resident 18 was admitted with diagnoses including phantom limb syndrome with pain and had Percocet documented in the narcotic records. During the facility’s review, two pages were removed from the narcotic book and the corresponding medication cards for Resident 18’s Percocet entries could not be accounted for. The investigation also found that Staff 3 had administered narcotic medications more frequently than other staff and had not allowed the CMA to administer the narcotics. The facility documented that the resident’s Percocet medication was unaccounted for. Resident 21 was admitted with diagnoses including palliative care and chronic pain and had a MAR order for morphine every four hours for moderate to severe pain. The MAR showed morphine was administered multiple times, with Staff 3 documenting most of the doses on one day. The facility’s investigation again found two pages removed from the narcotic book and the corresponding medication cards for Resident 21’s morphine could not be accounted for. Staff reported concerns about erratic medication disposal, crossed-out narcotic books without signatures for destruction, and the facility determined misappropriation of Resident 21’s medications had occurred.
Unsafe discharge planning and missing home health referral
Penalty
Summary
The facility failed to ensure community resources were in place for a safe and orderly discharge for a resident with mild cognitive impairment and a history of burns to the lower limbs. The resident’s care plan identified a shelter as the discharge destination and noted the resident had been homeless, with interventions to plan with community resources to support independence after discharge. Social services documented that the resident was told the discharge plan was unsafe, understood the concern, and chose to proceed as the responsible party. A discharge summary stated the discharge occurred because Medicaid had been denied and the resident was discharged to houseless status, with multiple discussions about safety concerns and the resident’s intention to live in a vehicle. The record also stated that a home care referral was completed for physical, occupational, and speech therapy, but there was no documented evidence that the referral was actually completed in the clinical record. A discharge MDS indicated the resident was cognitively intact and needed supervision or touching assistance to walk 10 feet. A physical therapy discharge summary documented the resident would ambulate 200 feet over uneven pavement with a front wheel walker and modified independence, but the resident’s ability to ambulate 200 feet over uneven pavement was not tested at the time of therapy discharge. A complaint later reported that the resident had been discharged back to a truck and fell, sustaining a spine fracture and skull fracture, and a hospital discharge summary documented admission with a shattered neck break, closed forehead fracture, and closed odontoid fracture after the resident was found on the ground outside the vehicle. The record further showed a second discharge episode in which the resident wanted to leave because of money concerns and was documented by nursing as not appearing cognitively able to live independently, with confusion. A physician note stated the resident did not have a safe discharge plan, appeared intermittently confused, and was advised to remain until cleared by neurosurgery, but the resident left before being seen and left against medical advice. There was no documented evidence that the resident signed out against medical advice or that a home health referral was completed. A discharge summary documented discharge to a business parking lot, noted the resident was a fall risk, had stopped pursuing liquidation of assets for Medicaid, and required assistance with toileting hygiene, bathing, and dressing, along with neck brace management and medication management. A discharge notice and order request also indicated the need for physical and occupational therapy, nursing, and social services.
Unsafe Water Temperatures on Falls Hall
Penalty
Summary
The facility failed to maintain safe water temperatures on Falls Hall, where the undated water temperature instructions stated domestic water temperatures were to be kept below 120 degrees Fahrenheit for burn prevention. During observations with the Maintenance Director, multiple resident sinks were measured above that limit, including 123.3 degrees, 124.7 degrees, 129.4 degrees, and 132.1 degrees Fahrenheit. The Administrator stated the water audits should not be done at the same time each week so temperature variances could be identified throughout the day, and that temperatures should be below 120 degrees Fahrenheit. Residents affected included individuals admitted with diagnoses such as anxiety, diabetes, stroke, heart disease, liver disease, respiratory failure, and hip fracture. Several residents were cognitively intact, while others had cognitive impairment or short-term memory issues. Some residents stated they liked the hot water or did not think the water was too hot, while others were not available for interview. The Maintenance Director stated he checked water temperatures weekly but usually did the audits in the morning and said the temperatures were never that high. Staff interviews showed mixed concerns about water temperature. An LPN stated residents did not report hot water concerns and that staff usually had to let the water run for a while for it to become warm enough for showers. A CNA stated residents usually reported the water was not warm enough. The observations and interviews showed that several resident sinks on Falls Hall had water temperatures above the facility’s stated safe limit.
Improper Hand Hygiene and Contaminated Surface Contact in Kitchen
Penalty
Summary
The facility failed to ensure proper hand hygiene and sanitary surfaces in the kitchen during food preparation and plating. On 9/15/25, Staff 19 (Dietary Manager) picked up and sorted meal tickets with gloved hands, then handled bread without washing hands or changing gloves. Staff 19 also opened the walk-in cooler with gloved hands and then handled raw foods without washing hands and donning clean gloves. On the same date, Staff 20 opened the walk-in cooler, removed condiments with bare hands, and then touched clean dishes without washing hands or donning gloves. On 9/17/25, Staff 19 picked up a clipboard with gloved hands and then handled cooked meat without washing hands or changing gloves. Staff 19 stated CNAs help residents complete meal tickets each morning and identified the tickets as a contaminated surface. Staff 19 also took a meal ticket with gloved hands, placed it on a cutting board, plated food, placed the ticket on the tray, and then picked up the next ticket and placed it on the cutting board. Later that day, Staff 19 sorted meal tickets with gloved hands, then placed a quesadilla on the same cutting board, cut it, and plated it without washing hands or changing gloves. Staff 19 later stated he was aware he should not touch items in the kitchen that are not sanitized with gloved hands without washing hands and donning clean gloves. Staff 20 also stated he was aware the walk-in cooler handle and meal tickets were contaminated surfaces and acknowledged touching both with gloved hands without washing hands or changing gloves afterward. On 9/19/25, the Administrator, Regional VP, and Regional Director of Clinical Operations acknowledged the facility failed to practice proper hand hygiene.
Infection Control and PPE Use During Isolation and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to follow infection control standards for two residents reviewed for hospice and transmission-based precautions. One resident had cellulitis, a history of a drug-resistant organism in the urine, intermittent incontinence, and cellulitis of the leg requiring precautions during high-contact activities. A Contact Isolation sign was posted outside the resident’s room directing staff to wear a gown and gloves before entry. Staff entered the room wearing a disposable gown and gloves, but after the resident exited the room, the staff member followed the resident into the hall after removing gloves and performing hand hygiene while still wearing the gown. The staff member stated the gown was not removed because the resident was walking down the hall and needed assistance. The infection preventionist later stated the gown should have been removed before exiting the room. Another resident had diagnoses including chronic kidney disease and bladder disorders, with a care plan noting risk for infection due to aspiration, pneumonia, an indwelling catheter, and multiple UTIs. The care plan called for Enhanced Barrier Precautions during high-contact care activities such as transferring and urinary catheter care. Two CNAs were observed assisting the resident with a mechanical lift transfer while wearing gloves only, and they stated they believed gowns were only needed for brief changes or emptying a catheter. The EBP sign posted at the room directed staff to wear gloves and gown for high-contact care including bathing, transferring, changing linens, toileting, and hygiene. Later, a hospice RN was observed changing the resident’s leaking catheter while wearing gloves only and no gown; the RN confirmed she changed the catheter with only gloves and acknowledged a gown should have been worn.
Failure to Obtain and Document Psychotropic Medication Consent
Penalty
Summary
The facility failed to inform residents of the risks and benefits of psychotropic medication use for 2 of 5 sampled residents reviewed for medications and dementia. One resident was admitted with diagnoses including depression and bipolar disorder and had a physician's order for daily Depakote, but the clinical record contained no evidence that the risks and benefits of Depakote were discussed with the resident. A regional director of clinical operations and an assistant director of nursing services later verified that the risks and benefits had not been reviewed with this resident. Another resident with dementia and a responsible party making medical decisions had an order for Depakote Sprinkles for agitation and mood, with the first dose given the day after the order was written. No informed consent from the resident representative was found during the initial record review, and a psychotropic medication consent was not located until later in the review. An RN stated she did not know informed consent from the resident representative was needed before administering Depakote Sprinkles, and an RN/assistant DNS stated staff were required to obtain informed consent from the resident or resident representative before administering a psychotropic medication.
Failure to Provide Bed Hold Notice and Ombudsman Notification
Penalty
Summary
The facility failed to provide a written bed hold notification, including reserved bed hold payment information, to Resident 6 or the resident’s representative at the time of transfer to the hospital, and failed to notify the Ombudsman of the transfer. Resident 6 was admitted to the facility in 1/2025 with diagnoses including kidney failure and was later transferred to the hospital on [DATE]. Review of the clinical record found no evidence that a written notice of the facility’s bed hold policy was provided and no documentation that the Ombudsman was notified. On 9/18/25 at 8:47 AM, the Regional Director of Clinical Operations and the Assistant Director of Nursing Services verified that the written bed hold notification was not provided and that the Ombudsman was not notified.
Failure to Follow Physician Orders for Treatment, Medications, and Bowel Care
Penalty
Summary
The facility failed to follow physician orders and failed to monitor a resident for a change of condition for 3 of 5 sampled residents reviewed for medications. One resident with heart disease had a critically low potassium level on laboratory testing, and the physician called the facility with orders to transport the resident to the emergency department. The resident refused transport because of the cost, and the record did not show that the physician was informed the order was not carried out or that the resident was monitored after refusing transport. The resident was transported to the hospital the next day and was admitted with NSTEMI. A second resident with kidney disease and a dialysis schedule on Mondays, Wednesdays, and Fridays had multiple ordered medications that were not administered as documented on the MAR, including allopurinol, midodrine, multivitamin, omeprazole, calcium acetate, and aspirin on several dates. Staff stated that medications were often not provided as ordered on dialysis days. A third resident with dementia had an order for bisacodyl if no bowel movement occurred for two days, but the bowel record showed multiple two-day periods without a bowel movement and the MAR showed the medication was not given after those periods. Staff stated the facility used a three-day bowel protocol, which did not match the physician order for two days.
Failure to Protect Residents from Neglect and Abuse
Penalty
Summary
The facility failed to protect residents from neglect and from verbal and physical abuse by Staff 24. Resident 47, who was admitted with quadriplegia and ALS, had a care plan directing staff to encourage frequent repositioning for pressure relief. The Documentation Survey Report showed Resident 47 was not repositioned on the night shift, and the neglect investigation found Staff 2 was notified that Resident 47 did not receive care during the night shift. Resident 47 stated Staff 5 entered the room, turned off the call light, did not provide care, and did not offer hydration or toileting. Staff 6 reported seeing Staff 5 enter the room and turn off the call light, and Staff 9 later reported Resident 47 complained that night shift had not taken care of him/her. Staff 1 stated staff were expected to provide care and services and not neglect residents. Resident 51, who was admitted with a diagnosis including infection, was involved in an incident during care provided by Staff 24. Staff 21 stated she was assisting Staff 24 when Staff 24 was rough while placing a chuck under the resident, told the resident he/she was not exactly easy to move when the resident objected, then jerked the chuck under the resident without counting and ignored the resident when he/she said it was hurting. Staff 16 stated Resident 51 reported on the following day that Staff 24 had been abusive during care. The facility investigation concluded it could not rule out abuse by Staff 24, and later the Administrator, Regional VP, and Regional Director of Clinical Operations acknowledged Resident 51 was abused by Staff 24.
Failure to Timely Report Abuse and Neglect Allegations
Penalty
Summary
The facility failed to timely report allegations of abuse and neglect for three residents. Resident 21 was admitted with a pelvic fracture and later stated that an RN and a CNA gave a suppository against the resident’s will and that the CNA forcefully placed a hand on the resident’s hip to hold the resident down. The resident said the incident was reported to the DNS and Administrator, and the facility reported the allegation to the State Agency the next day. Staff later stated they learned of the incident the day after it occurred, and facility leadership stated allegations of abuse should be reported to the State Agency within 2 hours. Resident 51, admitted with diagnoses including infection, reported being verbally and physically abused by a CNA. Staff learned of the allegation the same day and submitted a facility reported incident to the State Agency several hours later, but the facility records showed the alleged abuse was not reported timely. Resident 47, admitted with quadriplegia and ALS, was the subject of a reported incident in which a CNA reported that another staff member did not provide care during the night shift and turned off the call light without giving services. A former nurse’s aide student stated she observed the staff member enter the resident’s room and turn off the call light without providing care, and she reported the concern to the DNS between 6:00 AM and 7:00 AM. The Administrator stated she would expect an allegation of neglect to be reported to the State agency within 24 hours if no major injury occurred.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure the safety of a resident with severe cognitive impairment, leading to an elopement incident. The resident, admitted for a five-day respite stay, had diagnoses including Alzheimer's Disease, dementia, anxiety disorder, and restlessness. The resident was identified as a high risk for elopement due to dementia and exit-seeking behavior. Despite this, the facility did not follow the care plan, which included 15-minute checks and encouraging the resident to remain in supervised areas. The resident was found by law enforcement in a roundabout, approximately 1.8 miles from the facility, after walking alongside and crossing a busy highway. The resident's care plan included interventions to monitor every 15 minutes and redirect when wandering, but these were not followed. Visual checks were supposed to be conducted every 30 minutes but stopped nearly four hours before the elopement occurred. Staff interviews revealed that not all staff were aware of the care plan's safety checks, and some staff did not attempt to redirect the resident's exit-seeking behavior. The resident was last seen by staff at 6:30 PM, and the elopement was discovered when the police returned the resident to the facility at 7:45 PM. The facility's investigation noted that the resident was ambulatory, could almost run, and was a high risk for elopement and falls. Despite setting off two alarms and needing frequent visual checks, the resident was able to leave the facility by following another visitor out the door. Staff acknowledged the lack of individualized interventions in the care plan and the failure to follow the care plan, which contributed to the resident's elopement.
Removal Plan
- Current residents identified as elopement risks would have their care plans reviewed to reflect person centered care.
- All current residents would be reassessed for risk of elopement. Any identified residents' plan of care would be updated to include individualized, personalized interventions.
- The elopement book would be updated to include any newly identified residents.
- All facility staff would be educated on the residents identified at risk for elopement and their individualized care plan interventions as well as procedures to initiate if a resident eloped. Staff who were on leave or under COVID restrictions would be required to complete the education prior to returning work.
- Daily audits would be completed by the Interdisciplinary Team (IDT) to ensure residents were properly identified for elopement risk, elopement care plans were individualized, and staff followed care plan elopement interventions. Any identified issues would be immediately corrected.
- Daily audits would continue, then weekly for three months. Results of the audits would be presented to the QAPI team.
Failure to Maintain Comfortable Temperature Levels
Penalty
Summary
The facility failed to maintain comfortable temperature levels in Pine Meadow Hall, affecting the residents' comfort. Resident 26, who has ALS, reported that her/his room and the hall were too cold, causing discomfort. Despite reporting the issue to management and nursing staff, no action was taken to resolve the temperature problem. Observations confirmed that the room and hall were cold, with the thermostat set to 68 degrees. Staff 15 and Staff 16, both CNAs, acknowledged the cold conditions and resident complaints. Staff 14, the Maintenance Director, admitted to testing room temperatures without documenting results or conducting audits, and was aware of Resident 26's complaints. Staff 2, the DNS, verified the thermostat setting and acknowledged awareness of the resident's complaints, noting that the thermostat should be set between 71 and 81 degrees for comfort.
Failure to Provide Therapeutic Diets
Penalty
Summary
The facility failed to provide therapeutic diets to three residents, which placed them at risk for unmet nutritional needs. Resident 2, who was admitted with end-stage kidney disease and diabetes, had discharge orders for a diabetic diet. However, the Dietary Manager admitted that there were no prescribed recipes or portion control guidelines for preparing meals for residents requiring a diabetic diet. The Registered Dietitian acknowledged that therapeutic diets, including diabetic diets, should be printed and followed, but this was not done. Resident 23, admitted with a diagnosis of malnutrition, was supposed to receive nutritionally enhanced meals. However, the resident reported not receiving the ordered oatmeal for breakfast and was observed with a meal that did not include any beverages. The Dietary Manager confirmed that if a resident did not complete a meal order, the facility prepared whatever was on the menu, which sometimes did not include the resident's preferences. Similarly, Resident 28, who was on a low carbohydrate diet due to diabetes, reported receiving extra carbohydrates despite marking them out on the meal order and not receiving the fruit they ordered. The Dietary Manager acknowledged these issues, indicating a failure to adhere to prescribed dietary requirements.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to ensure that meals were palatable, attractive, and served at an appetizing temperature, affecting the quality of food provided to residents. This deficiency was observed in the kitchen and among three residents. Resident 9, who was admitted in 2023 with a diagnosis of cancer and was cognitively intact, reported that the food was always cold and the meat was chewy. A test tray delivered to surveyors confirmed that the plate warmer was cool to touch, the meat was hard, and the rice was lukewarm. Staff members, including the Director of Nursing Services (DNS) and a Regional Registered Nurse (RN), acknowledged these issues. Resident 23, admitted in 2024 with a diagnosis of malnutrition and also cognitively intact, experienced a similar issue with food quality. During lunch, Resident 23 received a taco casserole with raw hamburger, which was verified by the Dietary Manager. A test tray delivered to surveyors confirmed the same issues with food temperature and texture. Additionally, Resident 11, admitted in 2023 with a surgical infection and moderate cognitive impairment, reported that the food was cold by the time it arrived in their room. The test tray confirmed that the food was not hot, and the DNS acknowledged this problem.
Failure to Use Beard Restraints During Meal Preparation
Penalty
Summary
The facility failed to ensure that beard restraints were worn during meal preparation, which was observed in one of the sampled kitchens for sanitary food practices. This deficiency was identified through observation, interview, and record review. The facility's policy, dated January 2024, required that beards be clean, well-groomed, and completely covered with a beard covering. However, on May 28, 2024, at 8:10 AM, the Dietary Manager and a Cook were observed preparing food in the kitchen without beard restraints. The Dietary Manager indicated a lack of awareness regarding the requirement for staff to wear beard coverings. On May 29, 2024, at 12:01 PM, the Registered Dietitian acknowledged that staff were indeed required to wear beard restraints while working in the kitchen.
Failure to Obtain Informed Consent for Medication Administration
Penalty
Summary
The facility failed to obtain informed consent for the administration of medication to a resident, which was identified during an interview and record review. The resident, who was admitted in December 2019 with diagnoses including dementia, restlessness, and agitation, had a physician's order dated April 11, 2024, for buspirone, a medication used to treat anxiety. However, the consent form signed on the same date incorrectly listed buspirone as an antidepressant, detailing the risks and benefits of an antidepressant medication instead. On May 30, 2024, the Director of Nursing Services (DNS) confirmed that buspirone is an anxiolytic medication and acknowledged that the resident and their representative were not provided with informed consent for the correct medication classification.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to evaluate and accommodate a resident's preference for bathing times, leading to a deficiency in honoring resident choices. Resident 18, who was admitted in 2023 with diagnoses including stroke and anxiety, was cognitively intact and required partial to moderate assistance for bathing. The resident's care plan indicated that bathing should be provided according to their preferences twice a week. However, the resident consistently refused showers on multiple occasions in May 2024 because they were offered at night when the resident preferred to be in bed. Despite the resident's request for a different bathing schedule, no changes were made, and an investigation into the refusals was not initiated as expected. Staff acknowledged that the resident should have been informed about alternative shower schedules.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to ensure that advance directive information was provided to residents, affecting three out of four sampled residents. Resident 11, admitted with a surgical infection, was noted to have impaired cognition. Despite a care conference form indicating the presence of an advance directive, the Director of Nursing Services (DNS) confirmed that Resident 11 did not have an advance directive in their clinical record, nor was there documentation showing that advance directive information was provided. Family members of Resident 11 also stated they were not informed about advance directives. Resident 34, who was cognitively intact and admitted with a skin infection, stated they did not have or want an advance directive and confirmed that the facility did not provide any related information. Similarly, Resident 40, admitted with a UTI and also cognitively intact, reported not having an advance directive and not receiving any information from the facility. The Social Service Director acknowledged the absence of advance directives in the clinical records of Residents 34 and 40 and failed to provide documentation that advance directive information was given.
Failure to Provide Advanced Beneficiary Notice
Penalty
Summary
The facility failed to provide an Advanced Beneficiary Notice (ABN) to a resident who transitioned from a Medicare skilled stay to Medicaid coverage. The resident, who was admitted to the facility in August 2016 with a diagnosis of respiratory failure, had a skilled Medicare stay from January 10, 2023, through January 19, 2023. After this period, the resident continued to reside in the facility under Medicaid coverage. However, a review of the resident's medical record showed no evidence that an ABN was issued following the change in payor status from Medicare to Medicaid. This oversight was acknowledged by a Regional Nurse Consultant on May 31, 2024, indicating a lapse in the facility's process for notifying residents of their financial responsibilities when coverage changes occur.
Failure to Prevent Abuse by Agency CNA
Penalty
Summary
The facility failed to prevent abuse for three residents, identified as Residents 14, 21, and 31, who were all cognitively intact and had various medical conditions. Resident 14, who was admitted with a diagnosis including stroke, reported that a former agency CNA, Staff 23, provided rough personal care and attempted inappropriate actions during bowel care. Despite Resident 14's protests, Staff 23 continued the rough treatment. The facility's investigation confirmed that abuse occurred between Staff 23 and Resident 14. Resident 21, admitted with spinal stenosis, reported verbal and physical roughness from Staff 23. Despite asking for gentler care, Resident 21 experienced verbal abuse and rough handling. The facility's investigation concluded that Staff 23 was abusive toward Resident 21. Similarly, Resident 31, who had hemiplegia, reported emotional and physical abuse by Staff 23, including being called a liar and being handled roughly during care. The investigation confirmed that Staff 23 was abusive toward Resident 31 as well.
Failure to Revise Care Plans for Residents on Medications
Penalty
Summary
The facility failed to revise care plans for two residents, leading to a deficiency in care. Resident 2, admitted with end-stage kidney disease and stroke, was hospitalized due to a hematoma while on an oral anticoagulant. Upon discharge, the anticoagulant was discontinued, but the care plan was not updated to reflect this change, as acknowledged by the Resident Care Manager. Resident 34, diagnosed with dementia, was started on Ativan in March 2024. However, the care plan did not include specific interventions or causes for anxiety related to Ativan use. The Resident Care Manager confirmed that the care plan was not updated to include resident-specific behaviors or interventions after Ativan was initiated.
Failure to Follow Physician Orders and Care Plans
Penalty
Summary
The facility failed to adhere to physician orders for two residents, leading to unmet care needs. Resident 9, who was admitted in 2017 with diagnoses including end-of-life care and restless leg syndrome, was prescribed Benztropine to be taken every evening at bedtime. However, a review of the resident's clinical record for May 2023 revealed that Resident 9 missed eight doses of this medication. This lapse was confirmed by the Director of Nursing Services (DNS) on May 29, 2023, after Resident 9 reported going without the necessary medication for eight days. Resident 7, admitted in February 2024 with a diagnosis of depression, expressed feeling unsafe around another resident, identified as Resident 33. A care plan was established to prevent contact between Resident 7 and Resident 33, in accordance with Resident 7's preferences. Despite this, on May 30, 2023, Resident 33 was observed sitting next to Resident 7 in the dining room without staff intervention. The Social Service Director was informed and subsequently had Resident 33 moved. The Administrator and DNS later confirmed that the care plan was not updated after Resident 33 moved out of the shared room, acknowledging the need for ongoing staff training.
Failure to Schedule Audiology Exam for Resident
Penalty
Summary
The facility failed to schedule an audiology exam for a resident who was reviewed for communication needs. The resident, who was admitted in April 2023 with a diagnosis of stroke, was cognitively intact and had requested to see a hearing doctor as noted in a provider progress note dated January 24, 2024. Despite this request, the resident, who was hard of hearing and had been recommended hearing aids approximately eight months prior, did not have a hearing appointment scheduled. On May 28, 2024, the resident expressed difficulty hearing, and on May 29, 2024, the Social Service Director acknowledged the lack of a scheduled hearing appointment. A progress note from the same day indicated that the resident's son was contacted to confirm or schedule a hearing exam. On May 31, 2024, the RN Resident Care Manager confirmed awareness of the resident's hearing difficulties and acknowledged that the resident had not seen a hearing doctor.
Failure to Accurately Assess and Follow Orders for Pressure Ulcer Care
Penalty
Summary
The facility failed to accurately assess and follow physician orders for pressure ulcer care for two residents. Resident 4, who was admitted with diagnoses including stroke and aphasia, had a physician order to float their heels while in bed, apply skin prep to their heels each shift, and ensure a foam boot was applied to their right heel at all times. However, observations on 5/29/24 revealed that Resident 4's heels were resting on the bed and their feet were exposed to the air, contrary to the physician's orders. Staff interviews indicated a lack of communication and documentation regarding the resident's refusal to float their heels, and changes to treatment were not updated in the resident's clinical record. Resident 19, admitted with bladder cancer, had an open area on the sacrum that was initially documented as a small sacral pressure wound. However, subsequent evaluations revealed it was a Stage 4 pressure ulcer, indicating a deep tissue injury from the beginning. The facility failed to conduct weekly Skin and Wound Evaluations between 1/26/24 and 3/1/24, and the wound was inaccurately assessed and documented in the Treatment Administration Record (TAR) and physician orders. Staff acknowledged the inaccuracies in the wound assessment and documentation.
Failure to Provide Elopement Care Plan for At-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision for a resident who was at risk for elopement. The resident, admitted in April 2024 with a diagnosis of stroke, was identified as having moderate cognitive impairment and a moderate risk for elopement as per an evaluation conducted in May 2024. Despite this, a review of the resident's care plan on May 29, 2024, showed no evidence of an elopement care plan. Observations from May 28 to May 31, 2024, noted the resident ambulating with a walker throughout various areas of the facility, including hallways, the dining room, the front lobby, and occasionally other resident rooms. On May 30, 2024, the facility's administrator and DNS confirmed the resident's risk for elopement but acknowledged the absence of a corresponding care plan.
Failure to Monitor Dialysis Access and Provide Appropriate Diet
Penalty
Summary
The facility failed to implement orders and consistently monitor a dialysis access site for a resident with end-stage kidney disease and stroke, who was admitted in 2024. The resident required dialysis and had specific dietary needs to avoid high phosphorus and potassium foods. Despite a care plan revision on 5/24/24 to assess the dialysis shunt for bruit and thrill daily and provide diet according to orders, the May 2024 Treatment Administration Record (TAR) showed no post-dialysis monitoring of the site. The resident reported leaving for dialysis before breakfast and not receiving food until returning late for lunch. Staff acknowledged the need for daily monitoring of the dialysis site and the provision of meals during dialysis, but the Dietary Manager was unaware of the special meal accommodations required, and the diet restrictions were not revised to address the resident's needs.
Failure in Discharge Planning for Resident
Penalty
Summary
The facility failed to assist a resident with discharge planning arrangements, which led to confusion and anxiety for the resident. The resident, who was admitted with a surgical infection and had moderate cognitive issues, expressed a desire to return home. The family requested to be notified before discharge to prepare for the resident's care, but the facility did not specify what needed to be set up at the resident's home. During a care conference, the family requested a home evaluation and was informed that the resident required 24/7 support. However, the facility did not provide details on who would provide care or what equipment was needed for a safe discharge. The resident expressed confusion about the discharge process, stating that communication from the facility was lacking. The Therapy Director noted that the resident had exhausted therapy benefits and was not eligible for additional therapy, and there was uncertainty about who would provide care for the resident at home. The Social Service Director was unsure about the resident's living arrangements and did not provide the family with information on resources. The family and local unit reported that the facility did not communicate effectively or assist with the necessary arrangements for the resident's discharge, including a home evaluation and caregiver training.
Failure to Provide Non-Pharmacological Interventions Before PRN Antianxiety Medication
Penalty
Summary
The facility failed to ensure non-pharmacological interventions were provided prior to the administration of PRN antianxiety medication for a resident diagnosed with dementia. The resident's care plan, updated in March 2024, indicated a risk for side effects from Ativan, an antianxiety medication. In May 2024, the Medication Administration Record (MAR) showed that the resident was administered Ativan 53 times, with only one instance documented as ineffective. Progress notes from the same month revealed that Ativan was often given simultaneously with oxycodone, making it unclear if pain reduction could have alleviated the resident's anxiety. The notes lacked descriptions of the resident's anxiety manifestations or specific interventions attempted before medication administration. Interviews with staff members highlighted a lack of documentation and intervention prior to administering PRN antianxiety medication. A CNA noted that the resident experienced anxiety due to delusions and a desire to be with family, and that calling the family sometimes helped. An LPN stated that staff were required to document the behavior and interventions on the MAR or in progress notes, but this was not consistently done. The Resident Care Manager confirmed that staff should identify the cause of anxiety and provide specific interventions before administering medication. However, no documentation was provided to show that such interventions were attempted for the resident in question.
Failure to Administer Hypertensive Medication
Penalty
Summary
The facility failed to ensure the proper administration of a hypertensive medication, metoprolol succinate, for a resident with high blood pressure and end-stage kidney disease. The resident was admitted to the facility in 2024 and had a care plan revised on May 13, 2024, which included monitoring vital signs and administering medications as per physician orders. After being discharged from the hospital on May 24, 2024, with instructions to continue metoprolol succinate, the medication was last administered on May 21, 2024, and not resumed upon the resident's return. On May 31, 2024, the Resident Care Manager acknowledged that the orders were not double-checked as expected, resulting in the medication not being administered as ordered.
Failure to Honor Resident Food Preferences and Dietary Needs
Penalty
Summary
The facility failed to honor the food preferences of two residents, both of whom were cognitively intact and had specific dietary needs due to their diabetes diagnosis. Resident 22, admitted in April 2023, reported not receiving requested meal items on multiple occasions. For instance, the resident requested milk for cereal but was informed it was unavailable, and on another occasion, requested scrambled eggs but received a different meal. Similarly, Resident 28, who was on a controlled carbohydrate diet, reported receiving meals with carbohydrates despite marking them out on the meal order. The Dietary Manager, Staff 4, acknowledged the lack of written documentation regarding portion sizes and dietary restrictions for residents on specialized diets such as CCHO, NEM, or NAS. This lack of documentation contributed to the facility's inability to meet the specific dietary needs and preferences of the residents, as evidenced by the repeated instances of incorrect meal deliveries. The absence of clear dietary guidelines and documentation led to the unmet needs of the residents, as observed and reported during the survey.
Failure to Provide Required Immunizations
Penalty
Summary
The facility failed to provide necessary immunizations to a resident who was eligible for the Prevnar 20 vaccine. The resident, admitted in August 2023, had a diagnosis of chronic respiratory failure. Upon review, it was found that the resident was not offered the Prevnar 20 vaccine, despite being eligible. This oversight was acknowledged by the Director of Nursing Services during an interview.
Failure to Report Serious Fall Incident
Penalty
Summary
The facility failed to report an unwitnessed fall with serious bodily injury to the State Agency for a resident admitted in August 2023 with diagnoses including hip fracture, history of falls, and dementia with cognitive decline. On August 31, 2023, the resident was found in bed with a skin tear above the left eye and another on the right elbow, along with bruising and excess fluid in the elbow. The resident was sent to the hospital, where it was determined that the fall resulted in a fractured elbow requiring surgery and a laceration above the eye. Despite these injuries, the facility did not submit a Facility Reported Incident to the State Survey Agency. This was confirmed by the Administrator on April 16, 2024.
Failure to Investigate Unwitnessed Fall with Major Injury
Penalty
Summary
The facility failed to thoroughly investigate an unwitnessed fall with a major injury involving a resident who had a history of falls and was at risk for additional falls. The incident report indicated that the resident was found in bed with a skin tear above the left eye and another on the right elbow, and the resident was sent to the hospital with a fractured elbow requiring surgery. However, the investigation did not address critical details such as how the resident got back into bed, whether the roommate was a witness, or if the CNA was interviewed. Additionally, there was no information on why the resident was trying to go to the bathroom alone despite being care planned for assistance, and no documentation on whether care planned interventions were implemented or if abuse and neglect were ruled out. The unwitnessed fall with a major injury was also not reported to the state agency as required. The administrator confirmed that the investigation document provided for the resident's fall was incomplete and lacked thoroughness. The investigation failed to include statements from potential witnesses, details on the resident's condition, and an assessment of whether the care interventions were followed. This lack of a comprehensive investigation placed the resident at risk for additional falls and potential abuse, as the facility did not adequately address the circumstances surrounding the fall or ensure that proper protocols were followed.
Failure to Prevent Accident Hazards
Penalty
Summary
The facility failed to ensure the environment was free of potential accident hazards for a resident admitted with a neck fracture and a history of falls. On the evening of 8/15/22, a CNA found the resident on the floor in their bathroom, with the toilet detached from the floor and on its side. The Maintenance Director had been notified earlier that the toilet was loose due to stripped floor mounting screws and had placed the toilet against the wall for repairs the next morning. However, the Maintenance Director did not ensure that Out of Order signs were posted, the door was locked, or evening staff were notified, leading to the resident's fall.
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 14 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bend
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bend Transitional Care | 1 mi | ★★★★★ | 0 | 0 |
| Regency Care Of Central Oregon | 1.3 mi | ★★★★★ | 6 | 0 |
| Regency Redmond Rehabilitation And Nursing Center | 13.9 mi | ★★★★★ | 8 | 0 |
| Regency Prineville Rehabilitation And Nursing Cent | 28 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.