Avamere Rehabilitation Of Clackamas
Inspection history, citations, penalties and survey trends for this long-term care facility in Gladstone, Oregon.
- Location
- 220 E. Hereford, Gladstone, Oregon 97027
- CMS Provider Number
- 385203
- Inspections on file
- 18
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Avamere Rehabilitation Of Clackamas during CMS and state inspections, most recent first.
A resident with dementia and a history of elopement was sent unaccompanied to a medical appointment, despite care plan requirements for supervision. The resident arrived disoriented, and the clinic had to assign staff to monitor them. Facility staff assumed the transport driver would escort the resident, leading to a deficiency citation.
A facility failed to properly disinfect a shared glucometer between resident uses, leading to an Immediate Jeopardy situation. A staff member used alcohol wipes instead of EPA-registered disinfectant wipes and did not adhere to the required contact time, risking bloodborne illness transmission. A resident with HIV was among those affected, requiring frequent blood glucose checks with the shared device.
A licensed nurse failed to adhere to infection control standards by using alcohol wipes instead of EPA-registered wipes to clean a glucometer, and did not allow proper drying time between uses, risking bloodborne illness transmission. The facility's DNS confirmed the expectation for proper disinfection and rotation of glucometers.
A resident reported inadequate lighting in the dining room, affecting their participation in activities. Observations confirmed non-functioning ceiling lights and disrepair in the dining room floor. Shared bathrooms had stained caulking, and room four had peeling wall paneling. The Maintenance Director and Administrator acknowledged these issues, with no plan in place for repairs.
A facility failed to implement a resident-centered care plan for a resident with dementia, leading to a deficiency in maintaining the resident's well-being. The care plan included generic interventions that were not specific to the resident's needs, and refusals of ADLs and showers were inadequately addressed. Staff interviews confirmed that the care plan was not resident-centered, and some interventions were attempted but not documented.
A resident with dementia and diabetes repeatedly eloped from the facility due to inadequate care plan interventions and supervision. Despite being identified as a high elopement risk, the facility failed to update the care plan effectively, and door alarms did not alert staff. Staff interviews revealed a lack of awareness and communication about the resident's risk, leading to multiple unwitnessed exits.
Failure to Follow Elopement Care Plan for Resident
Penalty
Summary
The facility failed to adhere to care plan interventions for a resident identified as an elopement risk, resulting in an Immediate Jeopardy situation. The resident, who had diagnoses including dementia and congestive heart failure, was admitted to the facility with a care plan that required accompaniment by a responsible party for any off-premises activities. Despite this, the resident was sent alone to a new medical appointment via medical transport, arriving disoriented and unattended. The receiving clinic had to assign a staff member to monitor the resident due to the risk of elopement. Interviews with facility staff revealed a lack of understanding and communication regarding the resident's need for supervision during transport. Staff members assumed that the medical transport driver would escort the resident, despite the resident's known cognitive impairments and history of elopement. The facility's failure to ensure the resident was accompanied by a responsible party, as outlined in the care plan, placed the resident at risk and led to the deficiency being cited.
Removal Plan
- The care plan for Resident 32 has been reviewed and revised to include an escort for all appointments. The resident will continue to receive 15-minute checks.
- All staff on evening shift have been educated on the facility's elopement policy, with a special emphasis on transportation for appointments.
- All remaining staff will be educated on the facility's elopement policy before the start of their shift, with a special emphasis on transportation for appointments. All staff with no scheduled shift will have been educated.
- All residents in the facility have been reassessed for elopement risk, and care plans have been updated as necessary.
- To ensure ongoing compliance the DNS/designee will audit and assess all new admissions for risk of elopement, weekly for three weeks, and then monthly until substantial compliance is achieved.
- All findings to be reported to the Quality Assurance and Performance Improvement Committee.
Improper Glucometer Disinfection Between Resident Uses
Penalty
Summary
The facility failed to ensure proper cleaning and sanitization of a community-use glucometer between resident uses, which was identified as an Immediate Jeopardy situation. During an observation, Staff 3 was seen using alcohol wipes instead of the required EPA-registered disinfectant wipes to clean the glucometer after checking a resident's blood glucose level. Furthermore, Staff 3 did not allow the glucometer to dry for the manufacturer's recommended contact time before proceeding to use it on another resident. This improper practice was observed despite the facility's policy and manufacturer instructions requiring the use of specific disinfectant wipes and adherence to contact time. The deficiency involved a resident with a diagnosis of human immunodeficiency virus (HIV) who required blood glucose checks three times a day using a shared glucometer. The facility's failure to properly disinfect the glucometer placed residents at significant risk for bloodborne illnesses. The Director of Nursing Services (DNS) confirmed that the expectation was for staff to use microkill bleach wipes and rotate glucometers to ensure proper dwell times were reached, which was not followed by Staff 3.
Removal Plan
- Glucometers in the facility have been collected and disinfected using an EPA-approved disinfectant for bloodborne pathogens.
- Staff 3 was suspended, will receive 1:1 education/training on glucometer disinfection between uses, and dedicating CBG equipment for residents with diagnoses of bloodborne pathogens.
- Licensed nurses will be educated on the proper procedure for disinfecting blood glucose monitors and complete a Blood Glucose Monitoring Competency and will have dedicated CBG equipment for residents with bloodborne pathogens.
- Resident 15 was provided with dedicated blood glucose monitoring equipment.
- Residents in the facility will be audited for diagnoses of bloodborne pathogens and provided with dedicated blood glucose monitoring equipment if indicated.
- The Medical Director was notified. Residents potentially exposed also notified. Testing will be offered as requested.
- To ensure ongoing compliance, the DNS/designee will observe blood glucose monitor disinfection for routine blood glucose checks to ensure proper disinfection.
- All findings to be reported to the QAPI Committee.
Inadequate Disinfection of Glucometers
Penalty
Summary
The facility failed to ensure that staff adhered to professional standards related to the disinfection of common use glucometers, which placed residents at significant risk for bloodborne illness. During an observation, a licensed nurse, identified as Staff #3, was seen using alcohol wipes to clean a glucometer after obtaining a capillary blood glucose (CBG) reading for a resident. This action was contrary to the manufacturer's instructions, which specified the use of EPA-registered wipes for disinfection. The nurse then attempted to use the same glucometer for another resident without proper disinfection, prompting intervention by a State Surveyor. Further investigation revealed that Staff #3 was not allowing the glucometer to dry for the required contact time after using bleach wipes, as per the manufacturer's instructions. The Director of Nursing Services (DNS), identified as Staff #2, confirmed that the facility's expectation was for staff to use microkill bleach wipes between each glucometer use and to rotate glucometers to ensure proper dwell times were reached. This deficiency was noted under F880, indicating a failure in infection control practices.
Deficiencies in Facility's Physical Environment
Penalty
Summary
The facility failed to provide a comfortable and homelike environment, as evidenced by several deficiencies in the physical environment. Resident 24, who was cognitively intact and had been admitted to the facility in 2019 with diagnoses including hypertension and depression, reported inadequate lighting in the dining room, which affected their ability to participate in activities. During a Resident Council meeting, members also noted that several light bulbs in the dining room had been out for a while, making it difficult to see. Observations confirmed that three out of six ceiling lights in the dining room were not functioning, and the floor was in disrepair with black tape and buckling near the soda machine. Further observations revealed additional issues in the facility's physical environment. The shared bathrooms between rooms one and three, and rooms two and four, had brown and yellow stained caulking around the base of the toilets and appeared dirty. Room four had paneling peeling away from the wall under the window. The Maintenance Director confirmed these issues and stated that there was no plan in place to address the lighting, flooring, bathroom caulking, or wall paneling problems. The Administrator also acknowledged the need for repairs in these areas.
Failure to Implement Resident-Centered Care Plan for Dementia
Penalty
Summary
The facility failed to implement resident-centered care plan interventions for a resident diagnosed with dementia, leading to a deficiency in maintaining the resident's highest practicable level of well-being. The resident, admitted in 2020, had diagnoses including dementia with agitation and depression. The resident's care plan, revised in 2018, was supposed to be resident-centered to maximize function and quality of life. However, the care plan interventions were generic and not tailored to the resident's specific needs. The care plan included interventions such as giving chocolate to calm the resident, separating them from others, and notifying a physician if behaviors interfered with medical needs. However, these interventions were not specific to the resident and were not consistently documented or implemented. The resident's care plan also failed to address refusals of activities of daily living (ADLs) and showers adequately. The interventions for these refusals were limited to documenting refusals and re-approaching at a different time, with no other strategies documented. Staff interviews revealed that the resident often exhibited behaviors and ate meals in their room due to these behaviors, with staff keeping the resident away from others. The Director of Nursing Services acknowledged that the care plan was not resident-centered and that some interventions were attempted but not documented or included in the care plan.
Failure to Prevent Repeated Elopements
Penalty
Summary
The facility failed to re-evaluate and revise care plan interventions for a resident with a history of elopement, leading to multiple unwitnessed exits from the facility. The resident, diagnosed with dementia and Type 2 diabetes, was initially assessed as a moderate risk for elopement, which later increased to a high risk. Despite this, the care plan interventions were not adequately updated to prevent further elopements. The facility's door alarms failed to alert staff during these incidents, and staff were unaware of the resident's whereabouts or the need for increased supervision. The resident's care plan included interventions such as a Code Pink protocol and 15-minute checks, but these measures proved ineffective. Staff interviews revealed a lack of awareness and communication regarding the resident's elopement risk and the need for additional interventions. The facility's administration acknowledged the failure to implement further interventions or reassess the resident's risk, resulting in repeated elopements and placing the resident at risk of harm.
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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