Avalon Care Center - Portland
Inspection history, citations, penalties and survey trends for this long-term care facility in Portland, Oregon.
- Location
- 12640 Se Bush, Portland, Oregon 97236
- CMS Provider Number
- 38E173
- Inspections on file
- 21
- Latest survey
- July 25, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Avalon Care Center - Portland during CMS and state inspections, most recent first.
A resident with a history of cerebral infarction and depression was not properly assessed for the use of a power wheelchair, despite documented goals and improvements in fine motor and visual skills. Therapy sessions focused on related skills, but no direct evaluation with the power wheelchair occurred, and the resident's request for increased independence and socialization was not addressed through appropriate assessment.
Two residents with mental health diagnoses did not receive the required PASARR screenings. One resident with schizophrenia and anxiety did not have a PASARR II completed despite indications it was needed, and another resident with bipolar disorder and PTSD did not have a PASARR I screening on record. Staff confirmed these omissions during the survey.
A resident with dementia and PTSD, who had severe cognitive impairment, was not provided with activities aligned to their documented preferences, such as pet visits, listening to preferred music, group participation, or outdoor time. Despite staff and family confirming these interests, the care plan lacked these details, and the resident was observed sitting alone without engagement or inclusion in ongoing activities.
A resident with a right leg amputation who required two-person mechanical lift transfers was assisted by only one CNA without the lift, resulting in a fall. The CNA relied on the resident's statement about their transfer needs, but the care plan still required a mechanical lift and two-person assistance, which was not followed.
A resident with a history of UTIs was prescribed Bactrim for prophylaxis and later received cefuroxime, resulting in duplicate antibiotic therapy without documented review or rationale. Staff recognized the issue and attempted to clarify with the PCP, but no response was received and no justification for the dual therapy was documented, contrary to the facility's antibiotic stewardship policy.
A resident sustained second-degree burns due to the facility's failure to enforce its smoking policy. The policy required staff management of smoking materials, but residents were allowed to possess and use them independently. This led to an incident where a resident was injured while refilling another resident's lighter. Staff and residents confirmed the lack of policy enforcement, and the administrator acknowledged the safety failure.
The facility failed to store and handle food in a sanitary manner in one of its kitchens. Observations included uncovered, unlabeled, and undated food items in the refrigerator and freezer, as well as spilled prune juice. The administrator confirmed these issues.
The facility failed to protect residents from physical and sexual abuse, resulting in one resident sustaining injuries from an altercation with another resident and another resident being inappropriately touched by a fellow resident. Staff were aware of the behavioral issues but did not adequately monitor or intervene to prevent these incidents.
The facility failed to provide a written summary of a baseline care plan within 48 hours of admission for two residents. Both residents, admitted with serious health conditions, did not receive their baseline care plans, and staff members were unaware of the requirement to provide and review these plans.
The facility failed to develop a person-centered comprehensive care plan for a resident diagnosed with PTSD. Although the resident's admission MDS noted the PTSD diagnosis and indicated the need for interventions, the comprehensive care plan lacked focus, goals, or interventions for PTSD symptoms. The Social Services Director confirmed the oversight.
The facility failed to follow physician orders for a resident with lymphedema and erythema. The resident's ACE wraps were not applied on multiple dates in May, and the resident was observed wearing ragged wraps that had not been removed for a week. Staff confirmed the non-compliance with the physician's orders.
The facility failed to provide adequate care and hazard removal for two residents. One resident, with obesity and dementia, fell out of bed when only one staff member was present during care, despite a care plan requiring two. Another resident, with severe cognitive impairment, was found with electric burners in their room, which staff were unaware of until they were removed by the Administrator.
The facility failed to maintain oxygen equipment and ensure oxygen was administered as ordered for two residents. One resident with COPD had a dusty oxygen concentrator filter, and another resident with congestive heart failure received an incorrect oxygen flow rate. Staff acknowledged these issues, and the DNS confirmed the expectations for equipment maintenance and oxygen level checks.
The facility failed to accommodate a resident's lighting needs, leaving them unable to reach the overbed light switch due to a short cord. Despite reporting the issue, it remained unresolved. The Maintenance Director and Administrator acknowledged the problem and the need for repair.
The facility failed to obtain copies of advance directives and inform two residents of their right to formulate advance directives. One resident had a care plan indicating an advance directive, but no documentation was found in their health record. Another resident had no documentation or discussion about advance directives despite being their own responsible party.
A resident with severe cognitive decline and chronic conditions was sent out of the facility for an appointment without notifying her/his representative, as required by the admission agreement. The Administrator acknowledged this lapse in notification.
A resident with a non-pressure chronic ulcer and type 2 diabetes, who was moderately cognitively impaired, was found to have a gouge in the wall adjacent to their bed. The Maintenance Director acknowledged the issue and stated it should have been fixed before the resident moved in. The Administrator also deemed the condition unacceptable.
The facility failed to accurately document wound care for a resident with lymphedema and erythema. Despite physician's orders to apply and remove ACE wraps daily, records showed inconsistencies, and the resident reported wearing the same wraps for a week without removal. An observation confirmed the wraps were ragged and nearly falling off, and staff acknowledged the documentation inaccuracies.
Failure to Assess Resident's Ability to Use Power Wheelchair
Penalty
Summary
The facility failed to ensure a resident's right to a dignified existence and self-determination regarding the use of a power mobility device. A resident with a history of cerebral infarction and depression was admitted and had a goal, as documented in an occupational therapy evaluation, to operate a power wheelchair with standby assist to maximize socialization. Despite this, therapy records showed that while the resident received services aimed at improving skills related to power wheelchair use, no actual assessment involving the use of the power wheelchair was performed. Scheduled power wheelchair training sessions did not occur, and the decision to discontinue the use of the device was based on perceived deficiencies in tactile feedback and visual scanning, without direct assessment of the resident's abilities in the power wheelchair. Interviews and observations revealed that the resident expressed a desire to use the power wheelchair to increase independence and socialization, and staff noted improvements in the resident's functional use of hands and ability to perform self-care tasks. The resident was observed participating independently in activities requiring fine motor and visual scanning skills, and staff confirmed improvements in these areas. Despite these observations and the resident's normal cognitive function, the facility did not conduct a direct assessment of the resident's ability to safely use the power wheelchair, as confirmed by the Director of Nursing Services.
Failure to Complete Required PASARR Screenings for Residents with Mental Disorders
Penalty
Summary
The facility failed to ensure appropriate completion of PASARR (Preadmission Screening and Resident Review) screenings for two of three sampled residents with mental disorders or intellectual disabilities. One resident, admitted with diagnoses of schizophrenia and anxiety, had a PASARR I assessment indicating the need for a PASARR II due to the schizophrenia diagnosis, but no PASARR II was found in the electronic health record. Staff confirmed that the required PASARR II had not been completed. Another resident, admitted with bipolar disorder and PTSD, did not have a PASARR I screening available in the record at the time of the survey. Staff interviews confirmed that the PASARR I was not completed for this resident upon admission, as required by facility policy.
Failure to Honor and Provide Resident Activity Preferences
Penalty
Summary
The facility failed to ensure that activities were honored and provided according to the preferences and needs of a resident with dementia and PTSD, who had a severe cognitive impairment as indicated by a BIMS score of six. The resident's admission MDS documented that it was very important for them to be around animals, do favorite activities, go outside in good weather, and listen to preferred music. However, the care plan only noted a general enjoyment of music and did not include specific preferences such as pet visits, listening to chosen music, group activities, or going outside. Observations over several days showed the resident sitting alone in common areas with little to no staff interaction and not being included in group activities occurring nearby. Interviews with the resident, their representative, CNAs, and the Activities Director confirmed that the resident enjoyed country and older rock music, liked dogs, and would participate in activities if invited. Staff were either unaware of the resident's preferences or had not included the resident in one-on-one visits or group activities. The Activities Director acknowledged that key preferences were missing from the care plan and were not being offered. The Administrator confirmed that the care plan did not reflect the resident's activity preferences and that activities were not being offered as expected.
Failure to Follow Care Plan for Safe Resident Transfer
Penalty
Summary
A deficiency occurred when the facility failed to implement care planned transfer interventions for a resident with a right leg amputation who required two-person assistance with a mechanical lift for transfers from bed to a shower chair. Despite the care plan in place, the resident was transferred by a single CNA without the use of a mechanical lift, contrary to the documented requirements. This resulted in the resident experiencing a fall during the transfer process. Interviews revealed that the CNA acted based on the resident's statement that they no longer needed the mechanical lift and only required assistance from one staff member, as the resident was working with therapy on slide board transfers. However, the care plan at the time of the incident still required a two-person mechanical lift transfer, and staff were expected to review and follow the care plan. The Director of Nursing Services acknowledged that the care plan was not followed in this instance.
Failure to Review and Document Rationale for Duplicate Antibiotic Therapy
Penalty
Summary
A deficiency occurred when a resident with a history of urinary tract infections (UTIs) was prescribed Bactrim for UTI prophylaxis and later received a second antibiotic, cefuroxime, without documented review or rationale for the concurrent use of both antibiotics. The resident was initially admitted with acute kidney failure, dysuria, and urinary retention, and was placed on Bactrim for ongoing UTI prevention. After reporting symptoms suggestive of a UTI, the resident was evaluated in the emergency department, where no infection was found. Subsequently, the resident's primary care provider prescribed cefuroxime following a urine dipstick that showed trace leukocytes, resulting in the resident receiving both antibiotics simultaneously. Facility staff, including nursing and infection control personnel, recognized the duplicate antibiotic therapy and attempted to contact the resident's primary care provider for clarification regarding the necessity of both medications. Despite these attempts, there was no response from the provider, and no documentation was made to justify the dual antibiotic regimen. The facility's antibiotic stewardship policy required validation of antibiotic use for correct indication, dose, route, and duration, but this was not followed in this case, as there was no documented rationale for the continued use of both antibiotics.
Failure to Enforce Smoking Policy Leads to Resident Injury
Penalty
Summary
The facility failed to implement and enforce its smoking policy, resulting in a resident sustaining a second-degree burn. The facility's smoking policy, dated January 20, 2023, required that smoking and smoking paraphernalia be managed and distributed by staff, with residents returning all smoking materials to a centralized storage box after use. However, the facility did not enforce this policy, allowing residents to possess and use smoking materials independently. This lack of enforcement led to an incident where a resident, admitted in February 2024 with chronic kidney disease, sustained burns while refilling another resident's butane lighter. The incident occurred on October 4, 2024, when the resident set their hand on fire while attempting to refill the lighter. The resident suffered burns to the middle, ring, and little fingers of their left hand. Interviews with the resident and another resident confirmed that the facility did not enforce the return of smoking materials, and staff acknowledged the facility's inability to manage the smoking policy. The facility administrator admitted the failure to ensure resident safety concerning the possession and management of smoking paraphernalia.
Unsanitary Food Storage and Handling
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in one of its two kitchens, specifically the dining room kitchenette. During an initial tour, several issues were observed: a piece of cake with whipping cream was not covered, labeled, or dated; a small plastic container with an unknown substance was not labeled or dated; a covered plate with a pork chop, baked potato, and corn was not labeled or dated; a tray with multiple covered juice drinks was not labeled or dated; and an opened container of prune juice had spilled onto lower shelves and the floor. In the freezer, seven small plastic containers with unknown substances were not labeled or dated; two individual strawberry yogurt containers had a use-by date that had passed; two opened one-pint ice cream containers with resident names were not dated; an opened gallon of chocolate ice cream did not have a secure lid and was not dated; and three small plastic containers of fish snack crackers on top of the refrigerator were not labeled or dated. The administrator confirmed these items were not appropriately stored.
Failure to Protect Residents from Physical and Sexual Abuse
Penalty
Summary
The facility failed to protect the residents' right to be free from physical and sexual abuse, as evidenced by two incidents involving residents. In the first incident, Resident 12, who had dementia and a communication deficit, was found on the floor with multiple skin tears after an altercation with Resident 17, who had a history of physical aggression and dementia. Staff were aware of both residents' behavioral issues, including Resident 12's tendency to wander into other residents' rooms and Resident 17's aggressive response to personal space invasion. Despite this knowledge, the facility did not adequately monitor or intervene, resulting in Resident 12 being injured by Resident 17 during an altercation in Resident 17's room. Staff confirmed that Resident 12's fragile skin could easily tear from physical contact, which was evident in this incident. Both residents were unable to recall the altercation due to their cognitive impairments, but staff and a housekeeper witnessed the aftermath and confirmed the physical altercation and injuries sustained by Resident 12. The facility's failure to consistently check on Resident 12's whereabouts and intervene as necessary to protect residents' safety led to this incident of physical abuse. In the second incident, Resident 3, who was cognitively intact, reported that Resident 33, who also had dementia but was ambulatory, touched her/his breast inappropriately. Resident 3 stated that Resident 33 entered her/his room, made an inappropriate comment, and then grabbed her/his breast before leaving. This incident was witnessed by Resident 3's roommate, who confirmed the inappropriate touching. Resident 3 reported the incident to a nurse later that evening, and the nurse confirmed that Resident 3 did not exhibit any changes in mood or behavior following the incident. Resident 33 denied the inappropriate touching and did not recall the incident. The facility's failure to prevent this incident of sexual abuse highlights a lack of adequate supervision and intervention to protect residents from abuse by other residents.
Failure to Provide Baseline Care Plans
Penalty
Summary
The facility failed to ensure that a written summary of a baseline care plan was provided to residents within 48 hours of admission for two of the four sampled residents. Resident 7, admitted with diagnoses including kidney failure and anxiety, did not have a baseline care plan reviewed or provided. Resident 7 confirmed not receiving a baseline care plan. Staff members, including an LPN and an RNCM, were unaware that baseline care plans needed to be provided and reviewed with residents. Similarly, Resident 241, admitted with diagnoses including heart failure and high cholesterol, also did not have a baseline care plan reviewed or provided. Staff members again confirmed their lack of awareness regarding the requirement to provide and review baseline care plans with residents.
Failure to Develop Comprehensive Care Plan for PTSD
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for a resident diagnosed with post-traumatic stress disorder (PTSD). The resident was admitted in January 2024, and the Mood State CAA from the resident's February 2024 Admission MDS noted the PTSD diagnosis and indicated that the care plan should address PTSD symptoms with interventions to assist with mood. However, a review of the resident's comprehensive care plan, last revised in April 2024, revealed no focus, goals, or interventions for the resident's PTSD symptoms. The Social Services Director confirmed that although a PTSD evaluation was completed, the comprehensive care plan related to PTSD symptoms was not completed.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to follow physician orders regarding wound care for a resident diagnosed with lymphedema and erythema. The physician's order from April instructed staff to apply ACE wraps to the resident's lower extremities in the morning and remove them at night. However, the Treatment Administration Record (TAR) for May showed that the ACE wraps were not applied on multiple dates. Additionally, the resident was observed wearing ragged ACE wraps that had not been removed for a week, contrary to the physician's orders. Staff confirmed that the resident was not wearing the ACE wraps as ordered during an observation on May 31.
Inadequate Care and Hazard Removal for Two Residents
Penalty
Summary
The facility failed to provide adequate care and hazard removal for two residents. Resident 239, admitted with diagnoses including obesity and dementia, had a care plan requiring two staff members to be present during care. However, on one occasion, only one staff member was present, resulting in the resident rolling out of bed. This was confirmed by both the CNA and the Administrator. Resident 240, admitted with severe cognitive impairment, was found with two unplugged electric burners on the floor of their room. The resident intended to use them, but staff were unaware of their presence until they were discovered and removed by the Administrator.
Failure to Maintain Oxygen Equipment and Administer Oxygen as Ordered
Penalty
Summary
The facility failed to maintain oxygen equipment and ensure oxygen was administered as ordered for two residents. Resident 4, who was admitted with multiple sclerosis and chronic obstructive pulmonary disease (COPD), was observed using an oxygen concentrator with a thick layer of dust on the external filter. Staff acknowledged that the filter was not clean, despite the expectation that external filters should be cleaned once a month. This observation was confirmed by both an LPN and the Director of Nursing Services (DNS). Resident 21, admitted with congestive heart failure and chronic respiratory failure, was observed using an oxygen concentrator with a flow rate of 2.5 liters, contrary to the physician's order of 1.5 liters. Additionally, the external filter on this concentrator also had a thick layer of dust. Staff acknowledged the discrepancy in the oxygen flow rate and the unclean filter. The DNS confirmed that oxygen levels should be checked at the beginning of each shift and filters cleaned monthly.
Failure to Accommodate Resident Lighting Needs
Penalty
Summary
The facility failed to ensure resident needs and preferences related to lighting were accommodated for one resident reviewed for accommodation of needs. Resident 13, admitted with diagnoses including a non-pressure chronic ulcer and Type 2 Diabetes, had moderately impaired cognition. The resident reported on multiple occasions that the overbed light switch had a short cord, making it inaccessible. Despite reporting this issue to staff, it remained unresolved. The Maintenance Director acknowledged the problem and stated that maintenance issues should be reported through the facility's work order system or via word of mouth. The Administrator confirmed that residents should be able to control their lighting and that the pull cord needed repair.
Failure to Obtain and Discuss Advance Directives
Penalty
Summary
The facility failed to obtain copies of advance directives and inform residents of their right to formulate advance directives for two residents. Resident 8, admitted in August 2017 with diagnoses including Type 2 Diabetes and morbid obesity, had a care plan indicating the presence of a Living Will or other Advance Directive. However, there was no evidence in Resident 8's health record that the facility obtained a copy of the advance directive or discussed it with the resident since the care plan intervention was initiated in June 2023. The facility administrator acknowledged this oversight during an interview on May 30, 2024. Similarly, Resident 13, admitted in March 2024 with diagnoses including a non-pressure chronic ulcer and Type 2 Diabetes, had no documentation in their health record indicating the presence of an advance directive or that staff discussed the creation of one with the resident. Despite the resident being their own responsible party and having moderately impaired cognition, the facility did not address the advance directive discussion. The administrator confirmed this lapse during the same interview on May 30, 2024.
Failure to Notify Resident's Representative of Out-of-Facility Appointment
Penalty
Summary
The facility failed to notify a resident's representative of an appointment out of the facility. Resident 289, who was admitted in December 2016 with diagnoses including chronic congestive heart failure and type 2 diabetes, had severe cognitive decline as noted in an 8/29/22 CAA. The resident's admission agreement indicated that her/his representative/legal guardian was her/his daughter. On 11/10/2022, Resident 289 was sent out of the facility for an appointment, but there was no evidence in the health record to indicate that the representative was notified. The Administrator acknowledged this lapse in notification on 6/3/24 at 2:16 PM.
Failure to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment for a resident admitted in March 2024 with diagnoses including a non-pressure chronic ulcer and type 2 diabetes. The resident's cognition was moderately impaired as per the Admission MDS reviewed on April 4, 2024. On May 29, 2024, a gouge approximately 16 inches in length and 36 inches above the floor was observed in the wall adjacent to the head of the resident's bed. The Maintenance Director acknowledged the gouge on June 3, 2024, and stated it should have been fixed prior to the resident moving into the room. The Administrator also stated that the gouge was unacceptable and that residents' rooms should be painted and homelike before they move in.
Failure to Accurately Document Wound Care
Penalty
Summary
The facility failed to accurately document wound care being provided in accordance with physician's orders for a resident with lymphedema and erythema. The resident was admitted in January 2018 and had normal cognitive function as of January 2024. A physician's order from April 2024 instructed staff to apply ACE wraps to both lower extremities in the morning and remove them at night. However, the Treatment Administration Record (TAR) for May 2024 showed that the ACE wraps were documented as being off on multiple dates, despite the resident stating that the same ACE wraps had been worn for a week without being removed at night. An observation on May 28, 2024, confirmed the resident was wearing ragged ACE wraps that were nearly falling off. Staff later confirmed that the records regarding the ACE wraps were not accurately documented.
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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