F0656

D

Failure to Honor Resident’s Care Plan for Female Caregiver Preference During Nursing Assessment

Portland, Oregon Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement a resident’s care plan regarding caregiver gender preference during the provision of nursing care. The resident, admitted in July 2025 with diagnoses including type 2 diabetes and depression, had a 7/7/25 cognitive assessment showing a BIMS score of 15/15, indicating no cognitive impairment. The resident’s 7/25/25 care plan documented an individualized preference for female caregivers to promote comfort during care, and directed staff to ensure female caregivers were available when providing care. During a routine skin assessment on 2/17/26 at 10:19 AM, the resident reported that Staff 6 (RN), a male nurse, conducted the assessment without an additional female caregiver present in the room, contrary to the resident’s stated preference and the care plan directives.

Interviews with staff confirmed awareness of the resident’s care plan and the expectation to honor the resident’s preference. On 2/17/26 at 11:07 AM, Staff 5 (LPN) stated that standard protocol based on the resident’s care plan was to ensure at least one female caregiver was present during routine assessments, including skin assessments, and acknowledged that staff were expected to honor this preference. At 11:15 AM, Staff 6 (RN) acknowledged providing care to the resident but refused to answer whether a female caregiver was present. At 12:04 PM, Staff 8 (CNA) stated that the resident’s preference was for female caregivers only and reported that Staff 6 provided nursing services without a female caregiver in the room. At 3:26 PM, Staff 1 (Administrator) stated that Staff 6 failed to honor the resident’s needs and preferences by performing nursing services without ensuring female caregivers were present.