Ashland Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Ashland, Oregon.
- Location
- 135 Maple Street, Ashland, Oregon 97520
- CMS Provider Number
- 385197
- Inspections on file
- 24
- Latest survey
- December 8, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Ashland Post Acute during CMS and state inspections, most recent first.
A resident with a UTI experienced changes in condition and was transferred to the hospital on two occasions without documentation that their representative was notified. The DNS confirmed that family notification was required but did not occur in these instances.
Two residents were discharged without adequate coordination or verification of post-discharge support. One was sent home without confirming the availability of a friend to assist or assessing home safety, resulting in exposure to unsafe living conditions. Another was discharged with incomplete instructions, missing a follow-up appointment due to outdated paperwork. Staff did not ensure all necessary information and resources were provided prior to discharge.
A resident with depression was administered Lexapro without being informed of the medication's risks and benefits, and no signed consent was documented. The DNS confirmed that the required information was not reviewed and consent was not obtained.
A resident who was cognitively intact and unable to eat due to a feeding tube was repeatedly brought to the dining room during meal times, despite expressing distress and a desire not to attend. Family complaints were made, and staff acknowledged that this practice was undignified and inappropriate.
The facility did not provide proper wound care or ongoing assessment for a resident with a surgical incision, resulting in wound dehiscence and emergency transfer. Additionally, another resident's use of a power wheelchair was restricted without a formal assessment or documentation, despite care plan changes and staff concerns about safety.
A resident with a history of a left femur fracture and a stage 2 sacral pressure injury experienced a deterioration of the wound to an unstageable, infected state. Despite this change, staff did not notify the provider or update the care plan with new interventions, and the resident was subsequently hospitalized for the infected wound.
Due to a sudden reduction in CNA staffing after several were sent home for COVID-19, only one CNA was left to care for an entire wing, resulting in delayed meal delivery for residents on transmission-based precautions, late administration of scheduled pain medication, and missed personal care such as showers. Staff interviews confirmed that supervisory personnel were not promptly notified of the staffing shortage, leading to significant delays in meeting residents' needs.
Staff did not routinely check or maintain the chemical sanitizer levels in the kitchen's low temperature dish machine, resulting in the machine operating without the required sanitizer. The sanitizer solution container was found empty, and testing confirmed the sanitizer level was below the required standard.
A resident with a stroke history and mental health diagnosis was started on Depakote as a mood stabilizer without obtaining consent or reviewing the medication's risks and benefits, despite being cognitively intact. Staff did not secure consent because the drug was classified as an anti-seizure medication, even though it was used for mental health treatment.
Three residents experienced unmet needs related to their environment, including a resident not provided with a suitable bed despite complaints, another resident unable to be safely transferred due to lack of space in a shared room, and a third resident repeatedly left without access to a call light after care. Staff interviews and observations confirmed these issues, which were not addressed according to care plans or resident requests.
A resident who was cognitively intact and admitted with a stroke was not offered information about advance directives (AD), and there was no documentation in the medical record to indicate that AD information was provided or discussed. Staff confirmed that the new care conference form lacked a section to document the offer of AD information, resulting in a failure to follow facility policy.
A resident with PTSD and insomnia continued to receive Ambien nightly despite a psychologist's recommendation to transition to an alternative sleep aid. The resident was open to the change, but staff did not follow up on the recommendation, and the regional nurse later confirmed the medication had not been discontinued as directed.
A resident with a history of mental health disorders and behavioral concerns did not have PASRR II recommendations incorporated into their care plan. The care plan was not updated to include interventions such as providing books, art supplies, memory cues, or Crisis Team contact information, and staff interviews revealed a lack of follow-through in implementing these recommendations.
Three residents did not have individualized care plans addressing their specific needs: one resident's care plan lacked details about preferred times for incontinence care despite known preferences and refusals, another resident on hospice had no documentation of meaningful activities despite an assessment identifying them, and a third resident approved for independent smoking had no care plan for the management or storage of smoking materials, leaving staff unclear about safety procedures.
Two dependent residents did not receive meaningful activities tailored to their interests, as care plans lacked specific information and staff were unaware of individual preferences. One resident, cognitively intact and interested in group activities, was not informed about or encouraged to participate in events, while another resident on hospice with dementia spent extended periods in their room without engagement, as staff did not know what activities to offer.
Two residents did not receive appropriate follow-up care as ordered or requested. One resident with respiratory symptoms did not have timely nursing assessments or prompt communication of x-ray results showing pneumonia, leading to delayed intervention and hospitalization. Another resident and their family requested a urology appointment, but staff failed to schedule it despite being responsible for medical appointments.
A resident with a history of stroke and high fall risk, who required two staff and a mechanical lift for transfers, was left alone in a wheelchair after therapy while staff sought assistance. The resident attempted to self-transfer and fell. The facility did not complete the fall investigation or update the care plan to address this risk for over two weeks, delaying new interventions.
A resident with heart failure and kidney disease requested a dental appointment during a care conference, and the care plan noted oral health problems requiring staff coordination for dental care. Despite these needs and repeated requests, the responsible staff member did not schedule the appointment, and the regional nurse confirmed that immediate follow-up was expected.
A resident with a history of stroke and heart disease, who required meal assistance, was left waiting with a meal tray while food became cold due to delayed staff response and lack of communication about assistance needs. Observations also found that meal carts were left unattended and a test tray was served cold, indicating that food was not consistently served at safe and appetizing temperatures. Staff interviews confirmed inconsistent documentation and communication regarding meal assistance, leading to delays in meal service.
A resident with respiratory failure and chronic pain had a grievance submitted by family regarding concerns with oxygen administration, meal assistance, pressure ulcer care, and missing items. The facility did not document timely investigation or communicate findings to the complainant before a scheduled meeting, and the grievance policy lacked a clear timeline for resolution.
A resident with a history of spinal surgeries and chronic pain did not consistently receive scheduled showers or safe transfer assistance as outlined in their care plan. Staff failed to document or communicate missed showers, and a CNA used an improper bear hug transfer technique, leading to reported pain. There was no effective system in place to track missed ADL care or ensure staff followed updated care plans.
A resident with arthritis did not receive scheduled doses of Norco for pain due to a delay in obtaining a new prescription, resulting in missed medication administrations. Staff and pharmacy records confirmed the prescription was not sent promptly, and the DON was unaware of the issue.
A resident in palliative care with moderate cognitive impairment requested assistance with toileting but was told by a CNA to use their incontinence brief instead. The facility's Administrator intervened, ensuring the resident received the necessary help. The incident was reported, and the CNA was placed on administrative leave.
A facility failed to accurately assess MDS for a resident with a coccyx pressure ulcer. Despite treatment orders for the wound, both the Admission and Discharge MDS inaccurately indicated no pressure ulcer. This error was confirmed by the DNS, showing a lapse in proper documentation of the resident's condition.
A facility failed to provide necessary treatment information for a resident's coccyx pressure ulcer at discharge. The resident, admitted with diabetes, had a documented pressure ulcer, but the discharge summary lacked treatment details. This was confirmed by the DNS, highlighting a communication lapse with the receiving health care provider.
A resident with heart failure was not offered bathing assistance for over two weeks, as documented in their ADL records. This deficiency was confirmed by the DNS during an interview.
A resident's pressure ulcer was inconsistently assessed and improperly treated, with varying stages identified and inappropriate treatment ordered. The DNS acknowledged the discrepancies and confirmed the incorrect treatment for the wound.
A resident admitted with pressure ulcers had inconsistent and inaccurate documentation in their medical records. The records varied between indicating a Stage III ulcer, a Stage II ulcer, and a Deep Tissue Injury (DTI), with some assessments failing to acknowledge the ulcer entirely. These discrepancies were acknowledged by the DNS, indicating a deficiency in maintaining accurate medical records.
An agency nurse was found impaired and in possession of missing controlled medications intended for two residents, leading to her arrest. The facility staff discovered the misappropriation after observing the nurse's behavior and checking medication supplies. Despite the incident, no residents missed their medication doses.
Failure to Notify Responsible Party of Hospital Transfers
Penalty
Summary
The facility failed to notify the responsible party of a resident regarding two separate hospital transfers related to urinary tract infection (UTI) symptoms and changes in condition. The resident, admitted with a UTI diagnosis, experienced a change in mental status, abdominal pain, and inability to urinate, leading to an emergency department transfer on one occasion. On another occasion, the same resident reported ongoing abdominal pain and was again transported to the hospital for evaluation and treatment. In both instances, there was no documentation in the clinical record that the resident's representative was notified of the hospital transfers. The Director of Nursing Services confirmed that families were supposed to be notified but acknowledged that notification did not occur in these cases.
Failure to Ensure Safe and Coordinated Discharge Planning
Penalty
Summary
The facility failed to ensure safe discharge planning for two residents. One resident, admitted with cellulitis, was discharged home with recommendations for 24-hour care and home health services. However, the facility did not confirm with the resident's identified friend whether assistance would be available, nor did they notify the friend prior to discharge. The resident was discharged without verification of home conditions or provision of resources for in-home caregivers. Upon arrival home, the resident encountered unsafe living conditions, including the presence of rats and lack of running water, and had to seek shelter with a neighbor before being transported to the hospital for further discharge planning. Staff interviews revealed that the facility did not provide the resident with information about the risks of discharging without 24-hour caregivers, did not supply a list of local resources, and did not confirm the availability of the friend to assist post-discharge. Another resident, admitted with a fracture and cognitively intact, was discharged with instructions that included post-discharge appointments. However, the discharge paperwork did not include an updated appointment that was scheduled during a post-operative visit on the same day the discharge instructions were printed. As a result, the resident and family missed an important follow-up appointment. Staff acknowledged that the most current appointment information was not transcribed onto the discharge instruction sheet, leading to incomplete discharge instructions.
Failure to Inform Resident of Psychotropic Medication Risks and Benefits
Penalty
Summary
The facility failed to inform a resident, admitted with a diagnosis of depression, about the risks and benefits associated with the use of Lexapro, an antidepressant medication. A review of the resident's medical record and physician order dated 5/3/25 showed that the resident was receiving Lexapro daily. However, there was no documentation indicating that the risks and benefits of the medication had been discussed with the resident, nor was there a signed consent form for the medication in the record. This was confirmed by the Director of Nursing Services, who acknowledged that the required information had not been reviewed with the resident and that no signed consent was present.
Resident with Feeding Tube Taken to Dining Room During Meals
Penalty
Summary
A resident with a history of stroke and a newly placed feeding tube, who was cognitively intact, was admitted to the facility and was unable to ingest food. Despite being prohibited from eating, the resident was repeatedly taken to the dining room during meal times, where other residents were eating. The resident expressed hunger and a desire not to be present in the dining room during meals, as it caused distress. Family members reported complaints to staff regarding this practice, but the situation continued. A CNA acknowledged that escorting the resident to the dining room under these circumstances was undignified and inappropriate. Facility administration also recognized that this action failed to respect the resident's dignity.
Failure to Provide Wound Care and Assess Power Wheelchair Use
Penalty
Summary
The facility failed to provide appropriate wound care and assessment for two residents. One resident was re-admitted with a surgical neck incision that was almost healed and open to air. Documentation showed conflicting information about whether the incision was covered with a dressing, and there were no orders for dressing changes or ongoing wound assessments after readmission. Staff confirmed that wounds, including incisions, should be monitored weekly and that the resident always had a dressing in place due to a neck brace. However, staff did not recall the wound's appearance prior to a significant event where the incision fully dehisced, resulting in bleeding and emergency hospital transport. The Director of Nursing Services (DNS) acknowledged that staff did not obtain wound care orders or assess the incision after readmission. Another resident, admitted with a diagnosis of seizures and dependent on staff for mobility, had their power wheelchair use restricted due to safety concerns. The care plan was revised to prohibit use of the electric wheelchair, but the clinical record lacked a required Power Mobility Device Screen assessment. Staff interviews revealed that the resident sometimes used the power wheelchair for short periods, but no formal assessment was conducted to determine safety or appropriateness. The DNS confirmed that an assessment should have been completed and findings reviewed with the resident.
Failure to Notify Provider and Update Care Plan for Worsening Pressure Ulcer
Penalty
Summary
A resident was admitted to the facility with a left femur fracture and a stage 2 pressure injury to the sacrum. Upon admission, the care plan addressed the existing pressure ulcer. Over the course of the resident's stay, wound assessments documented a deterioration of the sacral pressure injury, progressing from stage 2 to an unstageable wound with suspected infection. Despite this change, there was no documentation that the resident's provider was notified of the wound's deterioration or suspected infection as of the assessment date when the change was noted. Additionally, the care plan was not updated to reflect the worsening condition of the pressure injury or to include new interventions after the wound became unstageable and appeared infected. Staff interviews confirmed that no provider notification occurred and no new interventions were added to the care plan following the wound's decline. The resident was later admitted to the hospital with an infected unstageable pressure injury to the sacrum.
Failure to Provide Adequate Nursing Staff Resulting in Delayed Care
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents, as evidenced by multiple observations and staff interviews. On the morning in question, several CNAs were sent home after testing positive for COVID-19, leaving only one CNA to cover an entire wing that typically required four. As a result, food trays for residents requiring transmission-based precautions remained unattended on carts for extended periods, with some residents not receiving their meals until significantly later than scheduled. Staff confirmed that the shortage prevented timely meal delivery and that residents would eventually be fed, but not according to the usual schedule. Additionally, the staffing shortage impacted medication administration. One resident, who was cognitively intact and had a diagnosis of arthritis, did not receive scheduled pain medication (Norco) until more than two hours after the scheduled time. The nurse responsible for medication administration reported being delayed due to the need to reorganize CNA assignments after the staffing shortage, and did not notify supervisory staff for assistance. This delay was confirmed by both the resident and staff involved in the medication pass. The lack of sufficient staff also affected personal care. Another resident, admitted with a history of stroke, did not receive a scheduled shower due to the staffing shortage, as confirmed by the CNA assigned to the wing. The staffing coordinator and DNS both stated they were not notified of the shortage until later in the morning, and the administrator, who was responsible for coordinating additional staffing, was not made aware of the issue until after the shortage had already impacted resident care.
Failure to Monitor and Maintain Dishwasher Sanitizer Levels
Penalty
Summary
The facility failed to properly follow dish sanitation practices in the kitchen, as required by professional standards and manufacturer instructions. The low temperature dish machine was supposed to maintain a sanitizer (chlorine) concentration of 50 parts per million. Although staff received training on the operation and chemical requirements of the new dishwasher, observations revealed that staff only monitored the temperature and soap levels, not the chemical sanitizer levels. Staff relied on an outside company to verify chemical levels, and did not perform routine checks themselves. During observation, a cook was seen using the dishwasher without verifying the sanitizer concentration, and the sanitizer solution container was found empty. When the chemical sanitizer level was tested by the administrator, it measured below the required 50 parts per million, and it was confirmed that no sanitizer was connected to the dish machine at that time. This failure to monitor and maintain proper sanitizer levels resulted in noncompliance with food sanitation standards.
Failure to Obtain Consent for Mood Stabilizer
Penalty
Summary
A resident admitted with a history of stroke and a mental health diagnosis was prescribed Depakote, an anti-seizure medication also used as a mood stabilizer. The resident was found to be cognitively intact according to the most recent assessment. Despite this, the facility did not obtain consent for the use of Depakote as a mood stabilizer, nor did staff review the risks and benefits of the medication with the resident. Staff interviews confirmed that consent was not obtained because the medication was classified as an anti-seizure drug, even though it was being used for mental health purposes.
Failure to Accommodate Resident Needs and Preferences in Environment
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of three residents in relation to their environment. One resident, admitted after shoulder surgery and at risk for pressure ulcers, repeatedly expressed that their bed was too narrow and uncomfortable, but staff were either unaware of the concern or informed the resident that a larger bed was not available. Another resident, who required a mechanical lift and assistance from two staff for transfers due to a stroke, reported that their shared room lacked sufficient space for safe transfers and wheelchair maneuvering. Staff confirmed that the room setup often required moving the bed at an angle or leaving the door open during transfers, which sometimes compromised privacy. A third resident, with cognitive intactness but impaired extremities from a stroke and heart disease, was observed without their call light within reach after care was provided. The resident stated this was a recurring issue, and staff acknowledged that the call light was not checked or placed within reach before leaving the room, despite care plan instructions. These deficiencies were identified through observations, resident and staff interviews, and record reviews.
Failure to Offer and Document Advance Directive Information
Penalty
Summary
The facility failed to ensure that a resident was offered information to formulate an advance directive (AD) as required by its policy. According to the facility's policy, if a resident does not have an AD, the resident or their representative should be given the option to accept or decline assistance in establishing one, and nursing staff are required to document the offer and the resident's decision in the medical record. In the case of a resident admitted with a diagnosis of stroke, the care plan indicated that AD or POLST documentation should be present in the medical record at all times. However, the quarterly social history review noted that the resident did not have an AD, and there was no indication that AD information was offered. Further review revealed that the resident was cognitively intact and, during an interview, stated that no one had discussed ADs with them. Staff interviews confirmed that while residents are typically asked about ADs upon admission and quarterly, and blank forms are offered if needed, the new care conference form no longer included a section to document that AD information was provided. Staff acknowledged that there was no documentation in the resident's record to show that AD information had been offered.
Failure to Discontinue Unnecessary Psychotropic Medication
Penalty
Summary
A resident with diagnoses of PTSD and insomnia was admitted to the facility in September 2023. The clinical psychologist's management plan dated April 16, 2025, recommended transitioning the resident from Ambien, a sedative, to an alternative sleep aid, and noted the resident was open to trying a different medication. Despite this recommendation, medication administration records for April and early May 2025 showed the resident continued to receive Ambien nightly from April 1 through May 7, 2025. On May 8, 2025, the regional nurse confirmed that the resident had not been transitioned off Ambien as recommended and acknowledged that staff had not followed up on the psychologist's recommendation.
Failure to Incorporate PASRR II Recommendations into Care Plan
Penalty
Summary
The facility failed to ensure that a resident's PASRR II (Pre-admission Screening and Resident Review) recommendations were incorporated into the care plan. The resident, who was admitted with a history of stroke, mental health disorders, suicidal ideations, and aggressive behavior, had a PASRR II evaluation completed that included specific recommendations such as providing environmental and social structuring, memory cues, art supplies, increased access to books, and the contact information for a Crisis Team. However, the care plan was not updated to reflect these recommendations, and staff did not implement the suggested interventions. Observations revealed that the resident's room lacked books, art supplies, and photos of loved ones, and the resident confirmed not having access to these items. Interviews with staff indicated a lack of clarity and follow-through regarding the handling and implementation of the PASRR II recommendations. The social services staff could not recall what was done with the recommendations, and the resident care manager did not see the PASRR II after its completion. The regional nurse confirmed that staff were expected to review and implement PASRR II recommendations, but this was not done for the resident in question.
Failure to Develop Resident-Centered Care Plans for Incontinence, Hospice Activities, and Smoking
Penalty
Summary
The facility failed to develop and implement individualized, resident-centered care plans for three residents with specific needs related to incontinence, hospice activities, and independent smoking. For one resident with arthritis and a history of depression and anxiety, the care plan did not include detailed instructions regarding the resident's preferred times for incontinence care, despite staff and resident reports that the resident was particular about care routines and often refused care from unfamiliar staff. The care plan also did not reflect the resident's current status, as the most recent assessments indicated the resident was cognitively intact and did not refuse care, yet staff interactions revealed ongoing issues with care refusals and unmet incontinence needs. Another resident admitted on hospice with cancer had an activity assessment identifying several meaningful activities, such as reading, listening to music, and being outdoors. However, the care plan failed to specify which activities were important to the resident, and staff were unaware that the care plan did not automatically include these preferences. As a result, CNAs did not have access to information about the resident's preferred activities, limiting their ability to provide individualized, meaningful engagement as identified in the assessment. A third resident, approved for independent smoking, did not have a care plan addressing the management and storage of smoking materials. Staff were unclear about whether the resident was allowed to possess smoking materials or where these items were kept, and the facility had not provided a lock box to secure them. The facility's smoking policy did not address individualized care planning for independent smokers, and staff acknowledged that the lack of a care plan prevented them from ensuring the safety of the resident and others regarding access to lighters and smoking materials.
Failure to Provide Meaningful Activities for Dependent Residents
Penalty
Summary
The facility failed to provide meaningful activities for two dependent residents, both of whom were at risk for social isolation. One resident, admitted with anxiety and sepsis and assessed as cognitively intact, expressed interest in group activities such as painting and crosswords, and valued social interaction. Despite this, there was no activity care plan addressing these interests, and the resident did not participate in any activities for 30 days. Staff interviews revealed that CNAs were unaware of the resident's preferences due to the absence of an activity care plan, and the Activities Director did not ensure residents were personally invited or that staff had access to necessary information. The resident was not informed about scheduled group activities and expressed disappointment at missing them. Another resident, admitted on hospice with cancer and dementia, also had an activity assessment indicating a strong preference for reading, music, being outdoors, and group activities. However, the care plan only generically stated staff should escort the resident to activities as desired, without specifying the resident's interests. Over a month, this resident did not attend any activities and was observed spending time in bed or in the room with a CNA present. Staff interviews indicated that resident-specific activities were often not included in care plans, and CNAs did not know what to offer if the resident could not communicate preferences. The Activities Director and DNS acknowledged the lack of meaningful activities and individualized care planning for this resident.
Failure to Assess and Follow Physician Orders for Resident Care
Penalty
Summary
The facility failed to properly assess a resident and follow physician orders regarding timely notification and documentation of a significant change in condition. One resident, admitted with arthritis and cognitively intact, underwent a chest x-ray following a physician's assessment due to respiratory concerns. However, there was no nursing assessment documented regarding the resident's respiratory status or the physical condition that warranted the x-ray. The x-ray results, which indicated pneumonia, were available but not promptly communicated to the physician or acted upon. The resident's condition worsened, with increased cough, abnormal lung sounds, and low oxygen saturation, eventually requiring hospitalization. There were no additional nursing assessments documented prior to the escalation of symptoms and hospital transfer. Another resident, admitted with heart failure and kidney disease, and their family requested a urology appointment during a care conference. Despite this request, staff responsible for scheduling medical appointments did not arrange the appointment, and the request was not followed up on. The staff acknowledged the oversight when interviewed, confirming that the appointment had not been scheduled as requested by the resident and family.
Delayed Fall Investigation and Care Plan Update After Resident Fall
Penalty
Summary
A resident with a history of stroke and resulting weakness, who was identified as high risk for falls, was admitted to the facility and required assistance from two staff members and a mechanical lift for transfers. The resident's care plan included interventions such as calling for assistance, keeping the call light within reach, and wearing appropriate footwear. After completing therapy, the resident was left alone in their wheelchair while staff left the room to find additional help for a mechanical lift transfer. During this time, the resident attempted to self-transfer from the wheelchair to the bed and experienced a fall. The facility did not complete the fall investigation in a timely manner, taking over two weeks to finalize the investigation and update the resident's care plan to include assistance back to bed after therapy. Progress notes during this period did not document that the fall was related to being left alone after therapy. Staff interviews confirmed that the investigation and care plan update were not completed within the expected timeframe, resulting in a delay in implementing new interventions to prevent further falls.
Failure to Provide Timely Dental Services After Resident Request
Penalty
Summary
The facility failed to provide dental services for a resident who was admitted with diagnoses including heart failure and kidney disease. During a care conference, the resident requested a dental appointment, and the care plan documented oral/dental health problems with instructions for staff to coordinate dental care and transportation as needed. Despite these documented needs and requests, the resident reported that staff had not scheduled the dental appointment after repeated requests. The staff member responsible for making dental appointments acknowledged that the resident's request was made during the care conference but confirmed that the appointment was not scheduled. The regional nurse stated that the expectation was for staff to follow up with a dental appointment immediately when requested by residents.
Failure to Serve Meals at Palatable Temperatures Due to Delayed Assistance and Poor Communication
Penalty
Summary
The facility failed to ensure that food was served at palatable temperatures for a resident who required assistance with eating and in the kitchen overall. One resident, admitted with a history of stroke and heart disease and assessed as cognitively intact but needing supervision for eating, was observed waiting in bed with a meal tray while her food became cold. Staff interviews revealed that the resident often received meals at her bedside without timely assistance, leading to cold food. The resident's care plan indicated a need for one-person assistance with meals, but this requirement was not reflected on the diet slip or meal ticket, resulting in communication lapses among staff. Staff acknowledged that meal assistance needs were not consistently communicated or documented, and that this contributed to delays in providing timely and warm meals. Additionally, observations showed that meal carts were left unattended and that staff did not always promptly distribute meals. A test tray left in a food cart for 22 minutes was found to have cold broccoli and lukewarm potatoes and meat, confirming that food was not maintained at appetizing temperatures. Staff interviews indicated that there was an expectation for all staff, including nurses, to assist with meal distribution, but this was not consistently practiced. The lack of clear communication, documentation, and timely staff response led to residents receiving food that was not palatable or at a safe and appetizing temperature.
Failure to Establish Timely Grievance Resolution Process
Penalty
Summary
The facility failed to maintain a grievance policy that included a reasonable timeframe for reviewing and resolving grievances, as evidenced by the handling of a grievance submitted on behalf of a resident with respiratory failure and chronic pain. The resident, who was cognitively intact and required assistance with eating, had a physician order for continuous oxygen. A family member submitted a grievance regarding concerns about the resident's oxygen, meal assistance, pressure ulcer interventions, and missing items. The care plan was reviewed and updated, and a meeting was scheduled, but there was no documented communication of findings or updates to the complainant until the scheduled meeting. Staff interviews revealed that the Director of Nursing spoke with a registered nurse about the oxygen issue, but this was not documented in the medical record, nor was the complainant informed of any findings prior to the meeting. The grievance officer only spoke with the complainant at the scheduled meeting, and the facility's policy did not specify a formalized timeline for grievance resolution. The regional nurse expected a response to the complainant within five days, but the facility's process did not ensure timely communication or resolution, and the policy required revision to address these deficiencies.
Failure to Provide Consistent ADL Assistance and Safe Transfers
Penalty
Summary
A deficiency occurred when a dependent resident with a history of respiratory failure, chronic pain, lumbar spinal fusion, and cervical spine surgery did not consistently receive assistance with activities of daily living (ADLs), specifically bathing and safe transfers. Documentation showed that the resident refused a shower on one occasion and received only one shower during a multi-week period, with other scheduled showers not attempted or documented. The resident's care plan required showers on specific days and one-person assistance with transfers, but staff failed to follow this schedule and did not consistently document refusals or communicate missed showers to nursing staff. Multiple staff interviews revealed a lack of a system to track missed showers, inconsistent documentation, and poor communication between CNAs and nursing regarding ADL care. Additionally, the resident reported pain after being transferred by a CNA using a bear hug technique, which was contrary to facility policy and the resident's care plan, especially given the resident's spinal history. Staff interviews confirmed that bear hug transfers were not permitted and that the resident's transfer needs were subject to frequent updates by therapy, requiring staff to review care plans regularly. Some staff were unaware of the resident's medical history and the risks associated with improper transfer methods. The Director of Nursing Services acknowledged that staff were expected to follow care plans for both transfers and scheduled showers, and that nurses should be tracking the completion of these tasks.
Failure to Ensure Timely Availability of Pain Medication
Penalty
Summary
A resident with a diagnosis of arthritis was admitted in June 2021 and was prescribed Norco to be administered every four hours for pain management. On January 30, 2025, the Medication Administration Record (MAR) showed that the resident did not receive Norco at four scheduled times throughout the day. Progress notes indicated that the medication was not available due to a delay in obtaining a new prescription, with staff waiting for delivery and notifying the physician of the missed dose. The physician was faxed for a new prescription later that morning, and the pharmacy confirmed that they did not receive the prescription until that day, after which it was filled. Staff interviews revealed that the process for obtaining new prescriptions involved notifying the nurse when a new order was needed, and the nurse would then request it from the physician. The Director of Nursing Services was unaware of the missed doses and unclear about why the prescription was not sent to the pharmacy following the physician's visit the previous day. The resident was noted to be cognitively intact at the time of the incident.
Failure to Assist Resident with Toileting
Penalty
Summary
The facility failed to treat a resident with dignity and respect, which was identified during an incident involving a resident who required assistance with toileting. The resident, who was admitted for palliative care and had a moderate cognitive impairment, requested help to use the bathroom. However, a CNA instructed the resident to use their incontinence brief instead of providing the requested assistance with a bedpan. This interaction was overheard by the facility's Administrator, who intervened and arranged for the resident to receive the necessary assistance from other staff members. The incident was reported to the State Survey Agency, and the CNA involved was placed on administrative leave pending an investigation.
Inaccurate MDS Assessment for Pressure Ulcer
Penalty
Summary
The facility failed to accurately assess Minimum Data Set (MDS) assessments for a resident reviewed for pressure ulcers. The resident was admitted to the facility with diagnoses including diabetes and heart failure and had a coccyx pressure ulcer upon admission. Despite physician orders to treat the coccyx wound throughout the resident's stay, the Admission MDS and Discharge MDS inaccurately indicated that the resident did not have a pressure ulcer. This discrepancy was verified by the Director of Nursing Services (DNS), highlighting a failure in accurately documenting the resident's condition in the MDS assessments.
Failure to Communicate Pressure Ulcer Treatment at Discharge
Penalty
Summary
The facility failed to provide necessary information to continuing care providers regarding the treatment of a coccyx pressure ulcer for a resident at the time of discharge. The resident, who was admitted to the facility in July 2024 with a diagnosis of diabetes, had a documented coccyx pressure ulcer as per the Treatment Administration Records (TARS) from July 2024. However, the Discharge Summary dated July 30, 2024, only noted macerated skin on the coccyx and did not include any treatment information for the pressure ulcer. This omission was confirmed by the Director of Nursing Services (DNS) on August 29, 2024, during an interview, indicating a failure to communicate essential treatment details to the receiving health care provider.
Failure to Provide Bathing Assistance
Penalty
Summary
The facility failed to provide bathing assistance to a resident who was unable to perform activities of daily living independently. The resident, admitted with a diagnosis of heart failure, was not offered the opportunity to bathe from mid-April to the end of April 2023, as documented in the resident's ADL Bathing records. This deficiency was confirmed by the Director of Nursing Services during an interview conducted in late August 2024.
Inconsistent Pressure Ulcer Assessment and Treatment
Penalty
Summary
The facility failed to properly assess and treat a pressure ulcer for a resident, leading to inconsistencies in the staging and treatment of the wound. The resident was admitted with a Stage III pressure ulcer, but subsequent assessments varied, identifying the wound as Stage II, a deep tissue injury (DTI), and unstageable due to slough. These inconsistencies were acknowledged by the Director of Nursing Services (DNS), who noted the discrepancies in the wound assessments. Additionally, the treatment ordered for the resident's wound was inappropriate for the identified stage. The physician's orders included the use of Santyl and a calcium alginate pad, which are not suitable for a Stage II pressure ulcer or DTI. The DNS confirmed that the treatment was incorrect and that the wound was closed upon her visual inspection. These actions and inactions placed the resident at risk for worsening pressure ulcers.
Inaccurate Documentation of Pressure Ulcer in Resident's Medical Record
Penalty
Summary
The facility failed to accurately document the medical records of a resident admitted with pressure ulcers. The resident, who had diagnoses including diabetes and heart failure, was admitted with a Stage III pressure ulcer according to the Admission Assessment. However, subsequent documentation was inconsistent, with a Skin Assessment indicating a Stage II ulcer and treatment orders for a Deep Tissue Injury (DTI). The Care Plan did not acknowledge the presence of a pressure ulcer, and the Admission MDS incorrectly stated that the resident had no pressure ulcers. Further inconsistencies were noted in the resident's medical records, with a Progress Note revealing the wound was unstageable due to slough, while other assessments continued to describe it as a Stage II or DTI. The Nutrition Admission Assessment inaccurately reported the resident's skin as intact, and the Discharge MDS again failed to document the pressure ulcer. These inaccuracies were acknowledged by the Director of Nursing Services, highlighting a significant deficiency in maintaining accurate medical records for the resident's pressure ulcer condition.
Misappropriation of Controlled Medications by Impaired Nurse
Penalty
Summary
The facility failed to protect residents from the misappropriation of controlled medications, specifically narcotic and sedative drugs, which were intended for two residents. An agency nurse, identified as Witness 1, was observed by other staff members to be impaired while on duty. Upon investigation by the Director of Nursing Services (DNS) and a Resident Care Manager, it was discovered that two bottles of methadone prescribed to one resident were missing, and another resident's Ativan supply was less than documented. Witness 1 was found with the missing methadone bottles in her possession and was subsequently arrested for theft. The residents involved in the incident included one with end-stage kidney disease prescribed Ativan on a PRN basis, and another with burn wounds and liver disease who was receiving scheduled methadone doses. The facility staff, including a Resident Care Manager and an LPN, reported concerns about Witness 1's behavior, noting her impaired state and inability to perform her duties. Despite the misappropriation, it was confirmed that no residents missed their medication doses on the day of the incident.
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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