Avamere Court At Keizer
Inspection history, citations, penalties and survey trends for this long-term care facility in Keizer, Oregon.
- Location
- 5210 River Road N., Keizer, Oregon 97303
- CMS Provider Number
- 385233
- Inspections on file
- 20
- Latest survey
- September 19, 2025
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Avamere Court At Keizer during CMS and state inspections, most recent first.
The facility failed to ensure a system was in place to receive and resolve grievances. Residents were unaware of how to file grievances, and no information or forms were readily available in common areas. A resident reported a lost mechanical lift sling with no resolution and was not offered a grievance form. The administrator confirmed the lack of signage and verbal reminders about the grievance process.
The facility neglected to ensure the availability of mechanical lift slings and briefs, leading to significant issues for residents. Multiple residents reported being unable to get out of bed due to the lack of slings, and staff confirmed frequent shortages of briefs and wipes, particularly on weekends. The Administrator acknowledged the issue, highlighting the facility's failure to provide necessary equipment and supplies, compromising residents' independence and well-being.
The facility failed to respond to resident council concerns expressed at three meetings, including issues with laundry services, food quality, supply shortages, and improper handling of clothes by aides. Staff confirmed the lack of responses, and the Administrator acknowledged the issue, which placed residents at risk for unmet needs and lessened quality of life.
The facility failed to ensure residents were notified of their rights both orally and in writing on an ongoing basis. A review of Resident Council Meeting minutes and staff interviews revealed no system to track and review resident rights, and no resident rights were posted in the facility. The Administrator acknowledged these deficiencies.
The facility failed to maintain RN coverage for at least eight consecutive hours a day for 9 out of 62 days reviewed. This deficiency was identified through a review of staffing reports for February 2023, September 2023, and May 2024. During an interview, the Staffing Coordinator and Human Resources acknowledged the struggle with RN coverage in February and September 2023, but no additional information was provided for May 2024.
The facility failed to ensure medications were secured and only accessible to authorized persons. An LPN found Ozempic stored in the DNS's office refrigerator, which was unlocked and in plain view. The DNS's office door was also observed propped open with the DNS not present. Both the Administrator and DNS acknowledged that medications should be locked and secured in the designated medication storage room.
The facility failed to properly label and store food, maintain complete temperature logs, ensure staff wore hair restraints, and maintain correct bleach concentration in cleaning solutions, leading to potential infection risks.
The facility failed to properly disinfect a shared glucometer between uses for four residents with type II diabetes, and did not maintain sanitary conditions for a resident's grab bars, which were worn and dirty. An LPN acknowledged the improper disinfection due to being busy, and an RNCM confirmed the grab bars needed replacement.
The facility failed to provide a dignified dining experience by not delivering meals to all residents at a table simultaneously. A resident with dysphagia waited 28 minutes for lunch while others ate and had their tables cleared. Staff acknowledged ongoing issues with meal delivery timeliness and incorrect meal cart placements.
The facility failed to revise the care plan for a resident with Huntington's disease receiving hospice care. Despite a significant change in condition indicating the resident was expected to live six months or less, the care plan was not updated to reflect hospice care needs. The administrator acknowledged the need for revision.
The facility failed to follow physician orders and implement bowel care timely for three residents, leading to missed medications and inadequate bowel management. One resident missed multiple doses of alpha-lipoic acid, another did not receive sevelamer carbonate during dialysis, and a third did not receive appropriate bowel care and had medications improperly crushed.
A resident with mild cognitive impairment was administered Quetiapine Fumarate without an appropriate diagnosis or documented behaviors justifying its use. Staff confirmed the diagnosis was inappropriate and that the resident did not exhibit behaviors indicating the need for the medication.
The facility failed to maintain a medication pass error rate below 5%, resulting in a 7.14% error rate. One resident received crushed extended-release metformin tablets, and another received a house stock multivitamin instead of the prescribed PreserVision AREDS supplement. Both errors were acknowledged by the facility's DNS and Administrator.
Failure to Ensure Grievance System in Place
Penalty
Summary
The facility failed to ensure a system was in place to receive and resolve resident and/or resident representative grievances. The facility's grievance policy indicated that residents and their family members should be able to express their concerns formally in writing. However, a review of the facility's grievance binder revealed no written grievances had been completed since September 2023. During a Resident Council meeting, residents stated they did not know how to file a grievance, and one resident mentioned that grievance forms used to be available in the front reception area but were no longer there. Observations confirmed that there was no information available in common areas about how to file a grievance, the timeframe for review, or the contact information for the grievance official and independent entities. Additionally, grievance forms were not readily available in the reception area or other common areas of the facility. A resident reported that a mechanical lift sling purchased for personal use had been lost months ago, and despite informing multiple staff members, no resolution was provided. The resident was not offered a grievance form and did not know how to file a grievance. The facility administrator acknowledged the lack of signage or verbal reminders about the grievance process and confirmed that instructions were only given in the Resident handbook upon admission. The administrator also confirmed that grievance forms were available at nursing stations but required residents to ask for them, which contributed to the lack of grievances filed since September 2023.
Neglect in Providing Mechanical Lift Slings and Briefs
Penalty
Summary
The facility neglected to ensure the availability of mechanical lift slings and briefs for residents, leading to significant issues for four sampled residents. Resident 29 reported that the facility often lacked mechanical lift slings and briefs, resulting in her/his spouse having to purchase briefs. On multiple occasions, Resident 29 was unable to get out of bed due to the unavailability of mechanical lift slings. The Resident Council Meeting minutes revealed ongoing concerns about the lack of mechanical lift slings and supplies, with residents expressing that the slings took three days to dry when laundered, causing them to remain in bed. Staff members confirmed the frequent shortages of briefs and wipes, particularly on weekends, and the necessity to borrow slings from other residents in emergencies. Resident 23 and Resident 27 also confirmed their inability to get out of bed due to the lack of slings, and Resident 27 had to wear the wrong size or no brief at all due to supply shortages. Staff 1, the Administrator, acknowledged the issue, stating that she had previously purchased mechanical lift slings but was unaware that the problem persisted. The deficiency was evident as residents were unable to perform activities of daily living (ADLs) and experienced social isolation and potential ADL decline due to the lack of necessary equipment and supplies. The facility's failure to provide adequate mechanical lift slings and briefs compromised the residents' independence and well-being.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to effectively respond to resident council concerns expressed at three resident council meetings. The facility's Resident Council Policy indicated that a Quality Assurance form should be used to track the council's concerns and suggestions, and a staff designee should fill out the Resident Council Response/Grievances forms immediately following the meetings. However, during the 5/29/24 Resident Council meeting, residents stated they did not feel heard about their concerns or suggestions and often did not receive a response from administration or departments regarding their reported issues. Specific concerns included delays and missing items in laundry services, food quality, supply shortages, and improper handling of clothes by aides, with no adequate responses or resolutions provided by the facility departments. Staff 13, who assisted the residents with Resident Council and wrote the response forms, confirmed the lack of responses from facility departments and acknowledged the residents' frustration. Staff 1, the Administrator, also acknowledged the lack of response to the Resident Council concerns and expected all concerns to be appropriately addressed in written form and given to the Resident Council for review. The failure to respond to resident council concerns placed residents at risk for unmet needs concerning issues of resident care and lessened quality of life.
Failure to Inform Residents of Their Rights
Penalty
Summary
The facility failed to ensure residents were notified of their rights both orally and in writing on an ongoing basis. The facility's revised 2021 Resident Rights policy indicated that copies of the resident rights were to be posted throughout the facility and that residents were to be informed about their rights and responsibilities upon admission and periodically thereafter. However, a review of past Resident Council Meeting minutes revealed no indication that resident rights were provided to residents during the meetings. The Resident Council stated they were not informed of resident rights on an ongoing basis and were unsure if any were posted in the facility or where to obtain them. Observations of the reception area and common areas confirmed that no resident rights were posted. Staff interviews revealed a lack of a system to track and review resident rights during Resident Council and no clear method for providing ongoing resident rights communication to residents who did not attend the meetings. The Administrator acknowledged the lack of ongoing resident rights information and the absence of posted resident rights in the facility.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day for 9 out of 62 days reviewed. This deficiency was identified through a review of the Direct Care Staff Daily Reports for the months of February 2023, September 2023, and May 2024. Specifically, there was no RN coverage on 2/4/2023, 2/11/2023, 9/1/2023, 9/3/2023, 9/10/2023, 9/11/2023, 5/6/2024, 5/10/2024, and 5/12/2024. During an interview on 5/31/2024, the Staffing Coordinator and Human Resources acknowledged the facility's struggle with RN coverage in February and September 2023. The Staffing Coordinator mentioned that RN schedules were adjusted to ensure appropriate coverage, but no additional information was provided regarding the lack of RN coverage in May 2024.
Failure to Secure Medications in Designated Storage Room
Penalty
Summary
The facility failed to ensure medications were secured and only accessible to authorized persons. During an observation, an LPN removed a box of Ozempic from the medication room refrigerator and stated it was not supposed to be stored there. Instead, the Ozempic was stored in the Director of Nursing Services' (DNS) office refrigerator. The DNS's office was located near the facility's entrance and adjacent to the reception desk. The refrigerator in the DNS's office was small, unlocked, and in plain view. The DNS stated that the Ozempic had been stored in her office refrigerator since the middle of the previous month and that her office door was locked when she was not present. However, the office door was observed propped open with the DNS not in the room, and the refrigerator was not locked. Upon review of the findings, both the Administrator and the DNS acknowledged that all medications were supposed to be locked and secured in the designated medication storage room to prevent unauthorized access. The facility's policy specified that medications should be stored properly and accessible only to licensed nursing personnel or staff members authorized to administer medications. The failure to secure the medications in the appropriate storage room placed residents at risk for drug diversion.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of food, as well as maintaining a clean and sanitary kitchen environment. During an initial kitchen observation, several containers of facility-made food items were found in the refrigerator with dates indicating they were kept beyond the maximum allowable period. Specifically, potato salad, chicken gravy, and country gravy were labeled with dates from April, well past the seven-day limit. The Dietary Manager acknowledged these items should have been discarded after three days. Additionally, the temperature logs for the snack refrigerator in the satellite kitchen were found to be incomplete on multiple dates, and the Dietary Manager confirmed that refrigerator temperatures were not monitored on weekends. Furthermore, a Dietary Aide was observed assisting with the lunchtime tray line without wearing a hair restraint, which is required when in the kitchen area. The Dietary Manager confirmed that staff are expected to wear hair restraints. Additionally, when the surveyor requested the Dietary Manager to test the bleach buckets for the correct chemical solution concentration, the test strips indicated zero bleach concentration, revealing that the wrong test strips were used and the chemical solution dispenser needed servicing.
Inadequate Disinfection of Glucometer and Unsanitary Grab Bars
Penalty
Summary
The facility failed to ensure appropriate disinfection of a shared glucometer for four residents observed for capillary blood glucose (CBG) monitoring. An LPN was observed using the same glucometer for multiple residents without thoroughly disinfecting it between uses. The LPN quickly flipped the glucometer side-to-side over the same disinfectant wipe between uses, failing to clean all areas and surfaces of the device. This practice was observed for four residents with type II diabetes, placing them at risk for bloodborne infections. The LPN acknowledged the failure to properly disinfect the glucometer, citing being busy and running behind as reasons for the oversight. The facility's policy required thorough disinfection of the glucometer between each use, which was not followed in this instance. Additionally, the facility failed to maintain sanitary conditions for a resident's bilateral grab bars. The grab bars, covered with coban adhesive, were observed to be worn, dirty, and stained. The resident, who had dementia and anxiety, used the grab bars to assist with repositioning in bed. The condition of the grab bars was acknowledged by a registered nurse case manager (RNCM), who confirmed that the coban adhesive was worn and needed replacement. The duration of the coban adhesive's placement was unknown.
Failure to Ensure Timely Meal Delivery
Penalty
Summary
The facility failed to ensure a dignified dining experience by not providing meals to all residents at a table at the same time. Resident 20, who has dysphagia, was observed waiting for her/his lunch for 28 minutes while other residents were eating and having their tables cleared. Staff acknowledged that Resident 20's meal was not delivered timely and that this was an ongoing issue, with meals often being late or placed on the incorrect meal cart. Both CNAs and the RNCM confirmed the delay and the failure to serve Resident 20's meal with the other residents in the dining hall.
Failure to Revise Care Plan for Hospice Resident
Penalty
Summary
The facility failed to ensure care plans were revised to accurately reflect the needs of a resident receiving hospice care. Resident 7, diagnosed with Huntington's disease, began hospice services on March 9, 2024. A Significant Change of Condition MDS on March 18, 2024, indicated the resident was expected to live six months or less and was receiving hospice services. However, the resident's care plan, last revised on December 15, 2023, did not reflect the anticipated decline in health condition or individual hospice care needs. The care plan focused on maintaining the current level of function for activities of daily living (ADLs) and mobility, without addressing the resident's hospice care requirements. The facility administrator acknowledged the need for care plan revision on May 31, 2024.
Failure to Follow Physician Orders and Implement Bowel Care Timely
Penalty
Summary
The facility failed to follow physician orders and implement bowel care timely for three residents, leading to missed medications and inadequate bowel management. Resident 151, diagnosed with diabetes, did not receive alpha-lipoic acid as prescribed on multiple occasions due to the medication being marked as unavailable. Staff acknowledged the missed doses but were unsure why the medication was not accessible, despite it being available through the facility's central supply system. This oversight resulted in the resident missing essential supplements for several days. Resident 8, who has end-stage renal disease and undergoes dialysis, did not receive sevelamer carbonate as prescribed on several occasions because the medication was not sent with the resident to dialysis. Staff admitted that there were times when the medication was not available, and the resident's family member confirmed that the medication was not always sent. The RNCM acknowledged that the resident should not have gone without the medication on dialysis days, indicating a lapse in medication management. Resident 20, with diagnoses including pneumonia, chronic constipation, and stroke, did not receive appropriate bowel care as per the facility's protocol. The resident went six and a half days without a bowel movement, and there was no documentation that bowel medications were offered or administered as required. Additionally, the resident's medications, including duloxetine and bisacodyl, were crushed despite being delayed-release, which could decrease their efficacy. Staff admitted to crushing these medications without proper verification, and the pharmacist confirmed that this practice was not recommended. The DNS acknowledged that staff failed to follow proper procedures for medication administration and bowel care.
Failure to Ensure Appropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure residents were free of unnecessary psychotropic medications, specifically for one resident diagnosed with mild cognitive impairment. The facility's Psychoactive Medication Management Guideline required staff to review admission orders for psychotropic medications, ensure an appropriate diagnosis for their use, and notify the provider if no supporting diagnosis was present. However, Resident 303 was administered 25 mg of Quetiapine Fumarate at bedtime without an appropriate diagnosis. The resident's health record did not document any behaviors or target behaviors that would justify the use of this antipsychotic medication. Staff interviews confirmed that the diagnosis of mild cognitive impairment was not appropriate for the use of Quetiapine Fumarate and that the resident did not exhibit behaviors indicating the need for such medication. The Director of Nursing Services (DNS) stated that all residents should be assessed for the appropriateness of medications upon admission and that behavior monitors should be put in place to monitor medication effectiveness. Despite these guidelines, Resident 303 was administered Quetiapine Fumarate without an appropriate diagnosis or documented behaviors, leading to the deficiency.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure a medication pass error rate of less than 5%, resulting in a 7.14% error rate. One incident involved a resident with type 2 diabetes who was prescribed metformin HCl extended-release (ER) tablets. During medication administration, an LPN crushed the ER tablets and mixed them with pudding before administering them to the resident. The LPN later acknowledged that ER medications should not be crushed and confirmed that she should have notified the provider if the resident preferred their medications crushed. The facility's Director of Nursing Services (DNS) stated that staff were expected to know that ER medications should not be crushed. Another incident involved a resident with spinal stenosis who was prescribed PreserVision AREDS, a specific eye health supplement. During medication administration, an LPN administered a house stock multivitamin with mineral instead of the prescribed PreserVision AREDS. The LPN stated it was preferred to administer the house stock multivitamin. Upon review, the DNS confirmed that the house stock multivitamin was not an alternative to PreserVision AREDS and that staff should have administered the prescribed supplement. Both incidents were reported to the facility's Administrator and DNS, who acknowledged the errors and the failure to follow physician orders.
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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