Aidan Senior Living At Reedsport
Inspection history, citations, penalties and survey trends for this long-term care facility in Reedsport, Oregon.
- Location
- 600 Ranch Road, Reedsport, Oregon 97467
- CMS Provider Number
- 385164
- Inspections on file
- 19
- Latest survey
- March 28, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Aidan Senior Living At Reedsport during CMS and state inspections, most recent first.
The facility failed to properly store, label, and handle food, risking foodborne illnesses. Observations revealed unlabeled and expired items in the kitchen and resident refrigerator. Staff did not follow glove-changing procedures during meal preparation. These actions violated facility policies, as acknowledged by staff.
The facility failed to administer medications as prescribed for two residents. One resident did not receive Ciprofloxacin eye drops due to being asleep, and staff did not notify the physician. Another resident did not receive Rexuliti for four days due to unavailability, and the physician was not informed. These actions placed residents at risk for delayed treatment.
A facility failed to create a personalized care plan for a resident, risking the resident's personal preferences not being honored. Despite the resident's expressed preferences for certain activities, the care plan lacked personalized goals and interventions. The Activities Director and DNS acknowledged this deficiency.
The facility failed to ensure that a multi-dose vial of Tuberculin was not expired, as it was found in the medication storage refrigerator with an open date exceeding the recommended usage period. The manufacturer's guidelines indicated that Tuberculin should be discarded after 30 days, while facility staff expected it to be destroyed after 28 days. This oversight placed residents at risk for ineffective medication and adverse reactions.
A facility failed to follow infection control standards for a resident with conjunctivitis, as staff were not informed of the need for precautions. The resident, with severe cognitive impairment, was prescribed Ciprofloxacin, but was often asleep during administration times. Staff, including CNAs and an RN, were unaware of the infection or did not implement necessary precautions, leading to a deficiency.
A resident with dementia and a history of falls was left unattended in the bathroom despite a care plan requiring supervision. This led to multiple unwitnessed falls. Staff misunderstood the care plan instructions, leaving the resident in situations where they could not be seen, contrary to the facility's expectations.
A resident with bilateral leg amputations fell and fractured their back due to a CNA's failure to follow the care plan requiring two-person assistance during shower chair transfers. The incident was exacerbated by the shower room's floor drain design, which caused instability in the shower chairs. Despite being aware of the care plan and the previous fall, the CNA transferred the resident alone, resulting in the fall and injury.
Improper Food Storage and Handling Practices
Penalty
Summary
The facility failed to ensure proper storage, labeling, and handling of food items, which put residents at risk for foodborne illnesses. During an initial kitchen observation, several items in the cook's freezer and walk-in freezer were found without open dates, including a clear plastic cup with frozen brown liquid, bags of frozen sliced bananas, blueberries, filled square pasta, and cherries. Additionally, the walk-in refrigerator contained several closed plastic containers labeled with use-by dates, and an opened bottle of key lime juice with no open date. A resident refrigerator also contained a bottle of whipped topping with no open date. Staff members acknowledged these findings and confirmed that the facility's policy required all foods to be labeled with an open date and expired foods to be discarded. During meal tray preparation and service, staff members were observed not following proper glove-changing procedures. Staff 51 and Staff 50, both cooks, did not remove their dirty gloves before handling food items until instructed to do so. The Dietary Manager confirmed that the policy required staff to change gloves before touching food items and after handling kitchen items. These lapses in food handling and storage practices were acknowledged by the staff, indicating a failure to adhere to established policies designed to prevent foodborne illnesses.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to follow physician orders for two residents, leading to deficiencies in medication administration. Resident 18, diagnosed with dementia and insomnia, was prescribed Ciprofloxacin eye drops for conjunctivitis, to be administered every two hours for two days. However, the medication was not administered as the resident was asleep during the scheduled times, and staff were instructed not to wake the resident due to agitation. The physician was not notified of the missed doses, which was confirmed by the facility's administrator, DNS, and regional nurse consultant. Resident 19, with diagnoses including dementia and depression, was prescribed Rexuliti for depressive disorder. The medication was not administered on four consecutive days because it was not available in stock, and there was a delay in ordering and receiving it from the pharmacy. Staff did not notify the physician about the unavailability of the medication, which was acknowledged by the facility's administrator, DNS, and regional nurse consultant. These failures placed the residents at risk for delayed treatment and unmet needs.
Failure to Develop Personalized Care Plan for Resident Activities
Penalty
Summary
The facility failed to develop a personalized care plan for a resident who was reviewed for activities, which put the resident at risk for not having their personal preferences honored. The facility's Care Planning policy required the care planning team, including the activities director/coordinator, to create an individualized comprehensive care plan for each resident. The resident, admitted in November 2024 with diagnoses of depression and diabetes, had a mild cognitive impairment and expressed preferences for activities such as being around animals, participating in group activities, and going outside. However, the care plan revised in March 2025 lacked personalized goals, interventions, or information under the activities focus area. During interviews, both the Activities Director and the Director of Nursing Services acknowledged the absence of personalized information in the resident's care plan.
Expired Tuberculin Vial Found in Medication Storage
Penalty
Summary
The facility failed to ensure that resident medication was not expired, specifically concerning a multi-dose vial of Tuberculin used for tuberculosis testing. During an observation of the medication storage refrigerator, it was found that an open and used multi-dose vial of Tuberculin had an open date of 2/18/25, which exceeded the recommended usage period. According to the manufacturer's insert, Tuberculin vials should be dated when opened and discarded after 30 days to prevent oxidation and degradation. However, the facility's staff, including an LPN and the Director of Nursing Services (DNS), stated that the expectation was to destroy Tuberculin vials 28 days after being opened. This discrepancy in practice placed residents at risk for lack of medication efficacy and potential adverse reactions from expired medications.
Infection Control Deficiency Due to Lack of Precautions for Conjunctivitis
Penalty
Summary
The facility failed to adhere to infection control standards for a resident diagnosed with conjunctivitis, leading to a deficiency. The resident, who had severe cognitive impairment, was prescribed Ciprofloxacin eye drops to be administered every two hours for two days. However, documentation revealed that the resident was asleep during multiple scheduled administrations, and there was no record of the resident being placed on infection precautions. Staff members, including CNAs and an RN, were either unaware of the infection or did not believe precautions were necessary, as evidenced by the lack of precaution signs and inconsistent communication during shift changes. The infection preventionist indicated that contact precautions with gloves should have been used, but no gowns were necessary, and these precautions would cease after 72 hours. Despite this, several staff members, including CNAs, were not informed of the resident's infection status, leading to potential exposure risks. The facility's administrator, DNS, and regional nurse consultant confirmed that staff should have been notified when a resident was on precautions, highlighting a breakdown in communication and protocol adherence within the facility.
Failure to Provide Adequate Supervision for Resident with Fall Risk
Penalty
Summary
The facility failed to ensure a safe environment for a resident with a history of falls and impaired safety awareness. The resident, admitted with dementia and disc degeneration, had a care plan indicating the need for assistance during toileting and not to be left unattended. Despite this, the resident experienced multiple unwitnessed falls in the bathroom. On one occasion, the CNA left the resident alone after assisting them onto the toilet, which led to a fall. The care plan was not revised after the initial fall, and the resident continued to be left unattended, resulting in further incidents. Interviews with staff revealed a misunderstanding of the care plan instructions, as staff left the resident unattended in situations where they could not be seen. The facility's administration acknowledged that the expectation was for staff to adhere to the care plan, which was not followed, leading to repeated falls. The failure to provide adequate supervision and adhere to the care plan placed the resident at risk for accidents.
Failure to Follow Care Plan Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to adhere to the care plan transfer interventions for a resident, resulting in a fall and subsequent hospitalization for a fractured back. The resident, who had above-the-knee amputations of both legs, diabetes, and dementia, was involved in a fall while being moved in a shower chair. The incident occurred when a CNA was backing up with the resident in the shower chair, and the wheel of the chair dropped into a recessed floor drain, causing the chair to flip over backwards. The care plan required two staff members to assist the resident during such transfers, but only one staff member was present at the time of the incident. The facility's investigation revealed that the CNA was aware of the requirement for two-person assistance but forgot to follow the care plan. The shower room's design, with a floor drain that caused instability for the shower chairs, was also a contributing factor. Staff members acknowledged the issue with the shower chairs and the drain area, noting that the smaller chairs were particularly problematic. Despite the availability of staff to assist, the CNA proceeded alone, leading to the resident's fall and injury.
Latest citations in Oregon
A resident with acute respiratory failure and heart failure had a documented Full Code status and a POLST specifying Attempt Resuscitation/CPR and Full Treatment. During night rounds, two CNAs found the resident not breathing, cool to the touch, with yellow skin and no pulse, but did not initiate CPR or call a code blue, instead going to notify an LPN. The LPN assessed the resident, confirmed absence of vital signs, noted the body was cold with mottling and no rigor mortis, and contacted the DNS, physician, and 911 for the coroner’s number, but did not start CPR or activate a code blue. No lifesaving measures were attempted despite facility policy requiring CPR for unresponsive residents without a valid DNR and the resident’s clearly documented full code status, leading surveyors to cite Immediate Jeopardy and substandard quality of care.
A resident with respiratory failure and pneumonia, who was Full Code and not on hospice, was found during routine rounds and suspected to be deceased. Nursing staff assessed the resident, noted there was no rigor mortis, confirmed death, and did not initiate a code blue or any resuscitation efforts despite the resident’s Full Code status. The facility later treated this as a potential neglect incident but did not report it to the State Agency within the required two-hour timeframe, as confirmed by the regional QA director.
A resident with chronic pain and a left below-knee amputation, who required supervision or touching assistance with ADLs, was discharged after returning from an outing shortly after midnight. Although discharge instructions noted the need for assistance and assistive devices, there was no documentation of referrals for medical equipment or home health services. Facility staff documented that the resident was discharged because they were out past midnight and believed Medicare would not cover the stay, did not issue a NOMNC, and recorded the discharge as voluntary despite the resident later reporting they had been “kicked out” and were sleeping on a friend’s couch with difficulty getting around. Staff interviews revealed no financial issues and indicated the resident had originally been scheduled for discharge at a later date.
A resident with a hip fracture and anxiety reported to social services that a CNA had been rough, told the resident to take themself to the bathroom, and instructed them not to get out of bed until a specified early morning time. The allegation was received by facility staff in the late afternoon, but the incident report was not submitted to the State Agency until the following day, exceeding the required 2-hour reporting timeframe acknowledged by the DNS. The deficiency concerns this untimely reporting of an abuse allegation, despite the CNA’s denial of any abuse.
A resident with hemiplegia, previously evaluated as not appropriate to self-administer any medications, was found to have open tubes of antifungal cream, anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) stored in a bedside drawer. Record review showed there were no MD orders for several of these topical products and no order permitting self-administration. An RN case manager confirmed the absence of orders, and the resident reported self-administering the medications, demonstrating a failure to ensure medications were administered only as ordered and in accordance with the resident’s assessed ability.
A resident with hemiplegia, previously evaluated as not appropriate to self-administer medications, was found with open containers of anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) in a bedside drawer. Record review showed no MD orders, no documented indication for use, and no monitoring for these medications. An RN case manager confirmed there were no orders and that staff did not administer or monitor the creams, while the resident reported self-administering them.
The facility failed to investigate multiple staff-reported allegations that one cognitively intact, wheelchair-using resident engaged in sexually inappropriate behaviors toward three other residents with significant cognitive and neurological impairments. Staff reported finding a resident with a ripped brief, crying and resisting care, and suspected sexual contact; they also reported that the alleged aggressor tried to take another resident into a shower room for sexual acts, attempted to video and kiss that resident, and encouraged a third resident to remove their top while present with a phone. CNAs, social services, and other staff stated they informed the administrator, DNS, HR, and unit management about these incidents and behaviors, but the administrator acknowledged that no investigations were conducted, despite being aware of the reports.
A resident with multiple sclerosis, care planned as dependent on two staff and requiring a Hoyer lift for transfers, was instead transferred by a CNA using a stand-pivot method without the lift or a second staff member. The CNA reported she had not read the resident’s care plan and described performing the transfer by giving the resident a “giant bear hug” and making several attempts to move the resident from chair to bed. The resident reported right flank pain and stated the transfer caused three broken ribs, although an x-ray later showed no rib fractures or dislocation and no visible injury was noted.
A resident with multiple sclerosis was admitted with physician orders for PT and OT, but review of the clinical record showed no documentation that these therapies were ever provided. The resident reported not receiving any therapy since admission, and the Director of Rehabilitation confirmed that no therapy services had been delivered during this period despite active orders, resulting in a failure to provide ordered rehabilitative services.
A dependent resident with dementia and a history of stroke, identified on the MDS as requiring staff assistance for showers, did not consistently receive scheduled bathing, and one CNA falsely documented that bathing had been provided. CNA task reports showed missed or undocumented baths on scheduled days, and an internal investigation confirmed that a bath recorded as completed on one date had not actually occurred. Staff interviews indicated that if bathing was not documented it usually did not occur, and that scheduled bathing was expected to be provided by staff.
Failure to Initiate CPR for a Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide CPR in accordance with a resident’s documented full code status. The facility’s Emergency Procedure CPR policy, initiated in 2001, required staff trained in CPR to initiate resuscitation on unresponsive residents who were not breathing unless there was a valid DNR order or clear signs of irreversible death such as rigor mortis. The policy further specified that if a resident’s DNR status was unclear, CPR should be started and continued until a DNR was confirmed. Resident 3 had been admitted with diagnoses including acute respiratory failure and heart failure and had a care plan and POLST on file indicating Full Code/Attempt Resuscitation and Full Treatment, including use of intubation, advanced airway interventions, mechanical ventilation, and transfer to hospital or ICU if indicated. On the night of the incident, a CNA (Staff 5) documented last vital signs for the resident at approximately 10:45 PM, with oxygen saturation of 92% on one liter of oxygen. At 2:00 AM, the resident was observed sleeping, breathing, and with a dry brief. Around 4:00 AM, Staff 5 and another CNA (Staff 8) entered the resident’s room and observed that the resident was not breathing, had yellow skin color, was cool to the touch, and had no palpable pulse. Both CNAs concluded the resident was deceased and went to notify the LPN (Staff 4) instead of initiating CPR or calling a code blue, despite having recent CPR training and later stating that, in retrospect, they would have started CPR and called for a code blue. When Staff 4 (LPN) entered the room, she assessed the resident and found no pulse, blood pressure, or respirations, noted the body was cold, with some mottling on the lower legs, pale/yellowish skin color, and no rigor mortis. Staff 4 did not initiate a code blue or CPR and instead contacted the DNS (Staff 2) and the physician, and then called 911 to obtain the coroner’s phone number. No lifesaving measures were attempted by any staff, despite the resident’s documented full code status and the facility policy requiring CPR in the absence of a valid DNR or signs of irreversible death. The DNS later stated she expected staff to call a code blue immediately, start CPR, call 911, and verify the resident’s code status. Surveyors determined that the facility failed to provide CPR according to the resident’s code status, placing all residents with full code status at risk and constituting substandard quality of care, with the noncompliance cited as Immediate Jeopardy and Past Noncompliance.
Removal Plan
- Administrator, DNS and nursing staff would be re-educated on the code blue process, how to locate a resident's code status in PCC and the POLST on file, and the importance of following individual resident care plans and orders.
- Resident code status would be cross-referenced with the PCC order, POLST scanned in binder, care plan, and resident dashboard.
- DNS or designee would monitor resident code status preferences for new admissions/returning admissions from hospitalizations.
- DNS or designee would audit code status for all new admissions and readmissions from hospitalization or ED visits, and share audit results with the QAPI committee to ensure substantial compliance is maintained.
- DNS or designee would complete a mock code.
- DNS or designee would complete mock codes.
Failure to Timely Report Alleged Neglect Involving Lack of CPR for Full Code Resident
Penalty
Summary
The facility failed to timely report an allegation of potential neglect related to CPR to the State Agency for one resident. The resident was admitted in February 2026 with diagnoses including respiratory failure and pneumonia and had a Full Code status, was not on hospice, and therefore was to receive CPR if found unresponsive. According to the facility’s investigation dated six days after the resident’s death, staff found the resident during routine rounds and suspected the resident was deceased, notified the nurse, and the nurse confirmed the resident was deceased. The investigation documented that at the time of the nurse’s assessment the resident did not have rigor mortis, yet the nurse did not initiate a code blue or any resuscitation interventions despite the Full Code status. The incident, which occurred on an identified date, was not reported to the State Agency until a later identified date, and the Regional Director of Quality Assurance confirmed that the facility did not report the incident within the required two-hour timeline. This failure to timely report the allegation of potential neglect involving the lack of CPR initiation for a Full Code resident constituted the deficiency identified by surveyors.
Failure to Ensure Safe and Orderly Discharge After Late Return from Outing
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and orderly discharge for a resident who was admitted with chronic pain, a left below-knee amputation, and post-surgical aftercare needs. An admission MDS completed shortly after admission documented that the resident was cognitively intact but required supervision or touching assistance with toileting, transfers, and bathing. Discharge instructions indicated the resident was being discharged home and that the resident’s current physical status required assistance and assistive devices, yet there was no documentation of referrals for needed medical equipment or a home health referral. The facility’s records did not show that these services or equipment were arranged prior to discharge. On the night in question, a nursing note documented that the resident returned to the facility after an outing at 12:23 AM, after the facility had notified the police because the resident’s location was unknown. The resident reported having been out with friends and being unaware of any concern. A social services note stated that because the resident was out past midnight, the resident was discharged from the facility, and a NOMNC was not issued because the resident left prior to the scheduled discharge and on their own initiative. A discharge summary documented that discharge instructions were reviewed with the resident, who refused to sign and was leaving voluntarily, and the voluntary consent form included a handwritten statement that the resident refused to sign. Later, the resident stated they had been “kicked out” for coming back late and were sleeping on a friend’s couch, finding it difficult to get around. Staff interviews showed there were no financial issues documented, that staff believed Medicare would not cover the resident if out past midnight, and that the resident had been scheduled for discharge several days later, while a regional director later characterized the situation as a clerical error and confirmed a normal discharge should have been completed.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to timely report an allegation of abuse to the State Agency after a resident reported that a CNA had been rough and verbally directive with them. The resident, who had been admitted with diagnoses including a hip fracture and anxiety, stated that the CNA was “kind of rough,” told the resident to take themself to the bathroom, and instructed the resident not to get out of bed until 6:00 AM. The resident reported this allegation of abuse involving the CNA to the social services staff member at 4:00 PM on 1/29/26. According to the facility’s investigation documentation, the allegation was received by staff at 4:00 PM on 1/29/26, and the Facility Reported Incident form was not received by the State Agency until 2:13 PM on 1/30/26. The DNS acknowledged that the facility became aware of the allegation at 4:00 PM on 1/29/26 and that it should have been reported to the State Agency within two hours but was not. The CNA denied abusing the resident or any resident, but the deficiency centers on the delay in reporting the allegation to the State Agency within the required timeframe.
Failure to Prevent Unauthorized Self-Administration of Non-Prescribed Medications
Penalty
Summary
Surveyors identified that a resident was self-administering non-prescribed topical medications despite a documented determination that they were not appropriate to self-administer any medications. The resident, admitted with hemiplegia, had a Self-Medication Administration Evaluation dated 11/13/25 indicating they were not appropriate to self-administer medications. During an observation on 3/19/26 at 7:50 AM with a RN case manager, open tubes of antifungal cream, anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) were found in the resident’s bedside table drawer. Review of the clinical record showed there were no physician orders for the anti-itch cream, hydrocortisone cream, or DMSO, and the resident did not have an order to self-administer any medications. The RN case manager confirmed the lack of orders for these medications, and at 8:10 AM the resident stated they did self-administer the medications found in their room. This constituted a failure by the facility to ensure the resident did not self-administer non-prescribed medications and to provide treatment and care according to physician orders and the resident’s evaluated ability to self-administer medications.
Unmonitored Self-Administration of Topical Medications Without Physician Orders
Penalty
Summary
The facility failed to ensure a resident’s drug regimen was free from unnecessary drugs by not providing adequate monitoring, indication for use, or physician orders for multiple medications. A resident admitted with hemiplegia in May 2024 had a self-medication administration evaluation dated 11/13/25 indicating they were not appropriate to self-administer any medications. During an observation on 3/19/26, an RN case manager found an open tube of anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) in the resident’s bedside table drawer. Record review showed no physician orders, no documented indication for use, and no monitoring for these medications. The RN case manager confirmed the resident did not have orders for the anti-itch cream, hydrocortisone cream, or DMSO, and that staff did not administer or monitor these medications. The resident stated they self-administered the medications found in their room, despite the prior evaluation determining they were not appropriate to self-administer any medications.
Failure to Investigate Multiple Allegations of Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to investigate multiple allegations of sexual abuse involving three residents. Resident 102, who had cognitive loss equivalent to a young child, legal blindness, and was non-verbal, was reportedly found with a ripped brief, crying, and resisting a brief change. Staff reported concerns that another resident, Resident 105, had performed or attempted to perform sexual acts on Resident 102. Staff members, including CNAs and social services, stated they informed facility management, including the Administrator and DNS, about the torn brief, Resident 102’s distress, and concerns that Resident 105 was being sexually inappropriate with multiple residents. Despite these reports and discussions in morning meetings, the Administrator acknowledged that no investigation was completed, believing the incident was based on staff assumptions. The facility also failed to investigate allegations involving Resident 103, who had Alzheimer’s disease and Parkinson’s disease. Staff reported that Resident 105 attempted to take Resident 103 into a shower room to perform sexual acts, and that a staff member intervened. The complainant later spoke with Resident 103, who stated that Resident 105 was “sick” and made bad comments. Other staff reported to human resources, the DNS, and the Administrator that Resident 105 attempted to take a resident into a shower room to unclothe the resident, and that Resident 105 attempted to video Resident 103, expressed a desire to kiss Resident 103, and get the resident into a shower room. The Social Service Director confirmed she reported these concerns to the Administrator, who stated he was aware of the incident but that no investigation was completed. A third failure to investigate involved Resident 108, who had Huntington’s disease and dementia. A staff member reported observing Resident 105 telling Resident 108 to take off their shirt and gesturing for them to do so, and stated they completed a written statement and gave it to the unit manager. Another CNA reported hearing that Resident 105 and other residents were laughing and encouraging Resident 108 to remove their top, and also reported observing Resident 105 rubbing other residents’ backs more physically than appropriate. Social services reported being told that Resident 108 was removing their top while Resident 105 was in the dining room with a phone, and that Resident 105 admitted to the behavior but described it as innocent. The Administrator stated he was aware of Resident 108 removing their shirt while Resident 105 was present, yet confirmed that no investigation was completed for this incident. These failures to investigate led surveyors to determine that the facility did not respond appropriately to alleged violations of sexual abuse for the three residents.
Removal Plan
- Residents 102, 103, and 108 received head-to-toe skin assessments completed by RCMs with no observed findings.
- Resident 105 was placed on one-to-one observations pending investigations.
- Staff 1 (Administrator) and Staff 2 (DNS) were re-educated on the facility's abuse policy, reporting, and thorough investigations.
- Social Services will interview all interviewable residents regarding abuse.
- Nurses will complete a head-to-toe assessment on all non-interviewable residents.
- All staff, including agency staff, will be re-educated on the facility's abuse policy and reporting.
Failure to Follow Care-Planned Hoyer Lift Transfer Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow a resident’s care plan interventions for transfers, resulting in a transfer being performed without required equipment and assistance. A resident admitted in February 2026 with multiple sclerosis had a 2/25/26 ADL care plan indicating the resident was dependent on two staff members for transfers and required use of a Hoyer (mechanical) lift. Despite this, on 2/28/26 a CNA (Staff 3) performed a stand-pivot transfer without the Hoyer lift and without a second staff member. The resident later reported that Staff 3 gave a “giant bear hug” and made several attempts to transfer the resident from chair to bed, after which the resident reported right flank pain and stated the transfer caused three broken ribs. An x-ray on 3/10/26 showed no rib fractures or dislocation, and the resident was assessed to have no visible injury. During interview, Staff 3 confirmed she had completed a stand-pivot transfer with the resident and acknowledged she had not read the resident’s care plan, and the Administrator confirmed that the resident had been care planned for a two-person Hoyer lift transfer at the time of the incident.
Failure to Provide Ordered Rehabilitative Services
Penalty
Summary
The facility failed to provide ordered rehabilitative services to a resident with multiple sclerosis. The resident was admitted in February 2026 with admission orders dated 2/24/26 for both physical therapy and occupational therapy. Review of the resident’s clinical record showed no documented evidence that any therapy services were provided as ordered. In an interview on 3/11/26 at 10:58 AM, the resident reported not having received any therapy since admission. During a separate interview on 3/11/26 at 10:40 AM, the Director of Rehabilitation confirmed that the resident had not received any therapy services from the date of admission through 3/11/26, despite the existing orders for physical and occupational therapy. This failure to implement the physician’s orders for rehabilitative services for this resident placed the resident at risk for a decline in range of motion.
Failure to Provide and Accurately Document Scheduled Bathing for a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a dependent resident received required assistance with activities of daily living (ADLs), specifically bathing, and inaccurate documentation that bathing had been provided. The resident, admitted in 10/2025 with dementia and stroke, had a 10/21/25 admission MDS indicating severe cognitive impairment and dependence on staff for showers. The facility’s 12/2025 CNA task report showed the resident was scheduled for bathing on day shift on Wednesdays and Sundays. On 12/24/25, the task report was blank for bathing, and on 12/28/25, the report documented that the resident received bathing and was dependent on staff for assistance. However, a 12/29/25 facility investigation determined the resident did not receive a bath on 12/28/25 and that it had been falsely documented that bathing occurred. A Facility Reported Incident form dated 12/31/25 further documented that on 12/28/25, a CNA (Staff 5) noted providing bathing to the resident but did not provide any type of bathing. Additional record review showed that the resident’s 3/2026 CNA task report contained no documentation that any type of bathing was provided on 3/11/26. Attempts to contact Staff 5 on 3/16/26 and 3/17/26 were unsuccessful. During interviews, another CNA (Staff 7) stated that on 12/28/25 she observed Staff 5 lay the resident down and, when she asked about bathing, Staff 5 said she would complete the resident’s bathing in the evening; Staff 7 stated she could not perform the resident’s bathing in the evening because she moved to a different hall on evening shift. Another CNA (Staff 21) stated that usually if bathing was not documented in the resident’s record, bathing did not occur. The Regional Nurse (Staff 31) stated that staff should provide scheduled bathing to residents.
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