Avamere At Three Fountains
Inspection history, citations, penalties and survey trends for this long-term care facility in Medford, Oregon.
- Location
- 835 Crater Lake Avenue, Medford, Oregon 97504
- CMS Provider Number
- 385126
- Inspections on file
- 20
- Latest survey
- January 21, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Avamere At Three Fountains during CMS and state inspections, most recent first.
The facility failed to follow proper infection control protocols, including PPE usage and linen handling. Staff did not change N-95 masks and face shields after exiting COVID-19 rooms, and linen carts were left uncovered in hallways. Additionally, hand hygiene was not consistently practiced, and Enhanced Barrier Precautions were not followed, increasing the risk of cross-contamination.
A resident was self-administering topical pain medications without an assessment or physician orders in place, contrary to facility policy. The resident, who was cognitively intact and experienced chronic pain, used Biofreeze and Icy Hot provided by their family. Staff were aware of the self-administration, but no nurse was informed, and no orders were documented. The facility's administrator and DNS acknowledged the oversight.
Two residents at the facility did not receive consistent restorative services, risking decreased range of motion. One resident, with cellulitis and peripheral vascular disease, had a care plan for exercise assistance but received limited services due to staff shortages. Another resident, with diabetes and cellulitis, required mobility assistance but also experienced service gaps, leading to increased stiffness and pain. Staff confirmed the lack of consistent care due to insufficient CNA availability.
A resident was prescribed an antibiotic for a UTI without proper indication, as the urine culture was not completed due to an incorrectly obtained sample. Despite the lack of culture results, the antibiotic treatment continued, highlighting a communication breakdown between nursing staff and medical providers.
The facility did not ensure that CNAs received the required 12 hours of annual in-service training, including dementia care. One CNA received only 6.75 hours, and another received 10.25 hours, both falling short of the requirement. The DNS and Assistant DNS confirmed the shortfall, acknowledging their responsibility for monitoring training hours.
An LPN at the facility administered ten medications prescribed for another resident to a resident with a recent cardiac pacemaker placement, respiratory failure, and end-stage kidney disease, leading to a drug overdose and hospitalization. The LPN failed to verify the correct resident and did not follow protocol for safe medication administration, resulting in severe consequences for the resident.
A resident was hospitalized after an LPN administered ten medications prescribed for another resident, followed by the resident's own medications without verifying with a physician. The LPN failed to follow proper identification protocols, leading to severe health complications.
The facility failed to protect residents from misappropriation of their narcotic medications, affecting three residents. Narcotic medication cards were signed to incorrect pages with forged signatures, and doses were missing. The incidents were reported to the physician, state agency, and law enforcement, and the facility acknowledged the misappropriation.
Infection Control Deficiencies in PPE and Linen Handling
Penalty
Summary
The facility failed to adhere to transmission-based precautions, resulting in potential cross-contamination risks. Staff members were observed not changing their N-95 masks and face shields after exiting COVID-19 positive rooms, contrary to the facility's PPE instructions. Additionally, contaminated equipment, such as stethoscopes, was improperly handled, and door handles were not sanitized, further increasing the risk of infection spread. Staff members, including a newly employed RN, were not adequately informed about the correct PPE protocols, leading to improper PPE usage and handling. The facility also failed to ensure proper linen transportation and handling. Linen carts were observed uncovered in hallways, including areas with droplet precautions, contrary to the facility's procedures. Staff members were not consistently following protocols for Enhanced Barrier Precautions, such as wearing gowns when required. Furthermore, hand hygiene practices were not consistently followed, as observed when a staff member changed their N-95 mask without sanitizing their hands. These deficiencies highlight lapses in infection control practices, placing residents and staff at risk for cross-contamination.
Failure to Assess and Document Self-Administration of Medications
Penalty
Summary
The facility failed to ensure a resident was assessed for self-administration of medications and that physician orders were in place for a resident reviewed for medications. The facility's policy required an interdisciplinary team to assess each resident's cognitive and physical abilities to determine whether self-administration was safe and appropriate. However, there was no assessment conducted for the resident in question, who was admitted with diagnoses including cellulitis and peripheral vascular disease. The resident was cognitively intact and experienced chronic pain, which occasionally interfered with sleep and daily activities. The resident self-administered topical pain medications, Biofreeze and Icy Hot, provided by their family, without any physician orders or assessments in place. Staff members, including a CNA and a CMA, were aware of the resident's self-administration of these medications, but no nurse was informed, and no orders were documented. The facility's administrator and DNS acknowledged the lack of assessment and the need for orders for the resident's self-administered topical pain medication.
Failure to Provide Consistent Restorative Services
Penalty
Summary
The facility failed to provide restorative services to two residents, leading to a risk of decreased range of motion. Resident 13, admitted with cellulitis and peripheral vascular disease, was cognitively intact and at risk for mobility decline. Despite a care plan indicating the need for restorative assistance with exercise bands and standing tolerances, Resident 13 received limited services. Documentation showed sporadic service provision, with gaps in care due to staff shortages. Resident 13 reported that services ceased after a period, and staff confirmed the lack of consistent restorative assistance. Similarly, Resident 30, admitted with diabetes and cellulitis, required assistance with mobility and was at risk for falls. The care plan included restorative exercises to maintain function, but records indicated minimal service provision. Resident 30 expressed concerns about the lack of services, noting increased stiffness and pain. Staff acknowledged the resident's complaints and the facility's failure to meet the scheduled restorative services due to insufficient CNA availability. Both residents were affected by the facility's inability to consistently provide the necessary restorative care.
Failure to Ensure Antibiotic Indication
Penalty
Summary
The facility failed to ensure that an antibiotic was indicated for use for a resident reviewed for unnecessary medications, placing residents at risk for developing drug-resistant organisms. The resident was admitted with a diagnosis of anxiety and later reported painful urination. A nurse practitioner ordered a urine sample and culture, and subsequently prescribed Ciprofloxacin before the culture results were finalized. The urine analysis was reviewed, but the culture was not performed due to an incorrectly obtained sample. Despite this, the antibiotic treatment continued without proper verification of its necessity. There was a communication breakdown between the nursing staff and the medical providers. The staff failed to notify the resident's physician about the incomplete urine culture and continued the antibiotic treatment based on the initial order. The physician stated that if she had been informed of the urine test results, she would have stopped the antibiotics, as the only symptom was burning with urination. The facility's infection prevention protocols were not followed, as staff did not reach out to the medical provider within the required timeframe after the antibiotic was initiated.
Deficiency in CNA In-Service Training Hours
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistant (CNA) staff received the required 12 hours of annual in-service training, including dementia care, for two out of five sampled CNAs. Staff 17 received only 6.75 hours of training, which did not include dementia training, despite working at the facility for over a year. Staff 17 acknowledged the incomplete training hours. Staff 18 received 10.25 hours of training in the past year, also falling short of the required 12 hours. Both the Director of Nursing Services (DNS) and the Assistant DNS confirmed the deficiencies in training hours for Staff 17 and Staff 18, acknowledging that they and the resident care managers were responsible for monitoring the in-service training hours. A call placed to Staff 18 for further verification was not returned.
Significant Medication Error by LPN
Penalty
Summary
The facility failed to ensure that a Licensed Practical Nurse (LPN) adhered to professional standards of practice for medication administration, resulting in a significant medication error for a resident. The incident involved the LPN administering ten medications prescribed for another resident to the affected resident, who had a recent cardiac pacemaker placement, respiratory failure, and end-stage kidney disease with dialysis. The error led to the resident experiencing a decline in condition and requiring hospitalization for a drug overdose. The medications administered included antipsychotics, an anti-diabetic medication, and other drugs not prescribed to the resident, causing an altered mental status and acute encephalopathy due to the overdose. The LPN realized the mistake after the resident commented on the number of medications being administered but did not verify the correct resident before giving the medications. The LPN also administered the resident's prescribed medications after realizing the initial error, further complicating the situation. The resident received additional medications, including an antidepressant, a blood thinner, vitamin D, artificial tears, and nitroglycerin, without consulting a physician. This lapse in practice and failure to follow protocol for safe medication administration led to the resident's hospitalization. The facility's Administrator and Director of Nursing Services (DNS) confirmed that the LPN made a significant medication error and did not follow the protocol for safe medication administration. The LPN also failed to provide appropriate documentation in the medical record for the other resident whose medications were administered to the affected resident. The incident highlights a critical failure in adhering to professional standards and protocols for medication administration, resulting in severe consequences for the resident involved.
Significant Medication Error Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, resulting in the hospitalization of Resident 101 for a drug overdose. On the evening of 8/16/23, Resident 101 was mistakenly administered ten medications prescribed for another resident, Resident 106, by Staff 6 (LPN). The medications included Advair, Clozaril, Olanzapine, Metformin, D-Mannose, Flomax, Combivent, Tylenol, Vitamin C, and Systane eyedrops. Staff 6 realized the error after the administration and noted a decrease in Resident 101's level of consciousness. The resident was subsequently sent to the hospital, where they were diagnosed with an accidental overdose and severe hypotension, among other complications. The incident report indicated that Staff 6 failed to follow the facility's protocol for medication administration, including not asking the resident to state their name or using any acceptable identifiers such as a picture identifier or nameplate on the resident's door. Additionally, Staff 6 administered Resident 101's own prescribed medications after realizing the initial error, further complicating the resident's condition. The resident received mirtazapine, Eliquis, vitamin D, artificial tears eye drops, and nitroglycerin after the initial error, which was not verified with a physician. Interviews with Staff 1 (Administrator) and Staff 2 (DNS) confirmed that Staff 6 made a significant medication error and did not follow the protocol for safe medication administration. Staff 6 admitted to the lapse in practice and acknowledged not verifying the correct resident before administering the medications. The failure to follow proper procedures and the subsequent administration of additional medications without consulting a physician led to the resident's hospitalization and severe health complications.
Misappropriation of Narcotic Medications
Penalty
Summary
The facility failed to ensure residents were free from misappropriation of their narcotic medications, affecting three residents. Resident 103, who was admitted with diagnoses including palliative care and chronic pain, had a narcotic medication card of oxycodone that was signed to another page in the facility's Narcotic Book with a different medication and resident name. The signature was identified as a forgery, and the medication card could not be located. Similarly, Resident 104, admitted with a fractured leg and chronic pain, had two cards of oxycodone missing. The narcotic log book pages indicated the medications were transferred to other books and pages, but these pages had different medications and residents on them, and the signatures were also identified as forgeries. The missing medications were discontinued, and an audit showed no further concerns in the narcotic books in use at the time of the investigation. Resident 105, admitted with a traumatic brain injury and neuralgia, had a dose of oxycodone signed out of the narcotic book after a medication count was completed and after the keys were handed off. The signature appeared to be forged, and the resident did not receive the dose. The missing dose of medication was not documented on the eMAR, and staff were unable to find it. The signature on the narcotic book page resembled those identified in the previous drug diversion investigation. The facility's investigation revealed that Staff 8 was the only one with keys to the cart during the timeframe the narcotics went missing. The incidents were reported to the physician, state agency, and law enforcement. The facility acknowledged the misappropriation of medications had occurred, and the investigation confirmed the forgery and misappropriation of narcotic medications for the three residents involved.
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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