Avamere Rehabilitation Of Coos Bay
Inspection history, citations, penalties and survey trends for this long-term care facility in Coos Bay, Oregon.
- Location
- 2625 Koos Bay Blvd, Coos Bay, Oregon 97420
- CMS Provider Number
- 385239
- Inspections on file
- 22
- Latest survey
- August 27, 2025
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Avamere Rehabilitation Of Coos Bay during CMS and state inspections, most recent first.
Two residents experienced significant medication errors when the facility failed to maintain an emergency supply of glucagon for hypoglycemia and did not administer anti-seizure and muscle relaxant medications at the prescribed times. One resident with diabetes had multiple severe hypoglycemic episodes without access to glucagon, leading to repeated hospitalizations, while another resident received several medications hours late and in close succession, with no provider notification or alert charting completed.
Multiple residents with cognitive and physical impairments experienced prolonged call light response times, often waiting from 25 minutes to over an hour for assistance with toileting, transfers, and other needs. Staff and nursing leadership acknowledged that response times regularly exceeded the expected five to fifteen minutes, especially during busy periods, resulting in unmet needs and resident discomfort.
Surveyors found expired medications, including Metamucil, an acid reducer, and insulin vials, in the medication storage room, a medication cart, and a treatment cart. Staff and the DNS confirmed that expired medications should have been destroyed and replaced, and that insulin vials were not discarded within the required 28-day period after opening.
Surveyors found that the kitchen ice machine's drainpipe was installed without an air gap, as observed with the Dietary Manager. The issue had been previously identified by maintenance staff but was not corrected, and the Administrator was unaware of the deficiency prior to the survey.
The facility did not follow physician orders for four residents, resulting in failures such as lack of monitoring for fluid overload, missed and unavailable glucagon for hypoglycemia, unimplemented continuous glucose monitoring, incorrect insulin dosing, delayed antibiotic administration, and missed tube feedings. Staff acknowledged these errors and confirmed that orders were not consistently double-checked.
A resident with incontinence and diabetes did not consistently receive the correct size incontinence briefs as care planned, due to regular supply back orders. Staff confirmed that the resident often had to use smaller, uncomfortable briefs for several days every two weeks, and the issue was known to both supply and social services staff.
A resident with diabetes was hospitalized after experiencing low oxygen saturation, rapid pulse, and diarrhea, but the facility did not notify the resident's listed emergency contact or family member. The resident, who was cognitively intact, expected her family to be informed, and the family member confirmed she was not notified, only learning of the hospitalization after the resident returned and called her. The DNS stated staff did not notify family because the resident was her own responsible party.
A resident with heart failure and moderate cognitive impairment, who was prescribed an anticoagulant, developed unexplained bruising. Staff identified and reported the bruise, but the care plan was not updated to include the physician's order for anticoagulant therapy, despite the resident's increased risk for bruising and staff awareness of the medication.
A resident with a history of leg fracture and high fall risk was left unsupervised on a bedside commode after a CNA, unaware of the supervision requirement, left to assist another resident. The resident activated the call light and waited 21 minutes before self-transferring back to bed, contrary to the care plan instructions for continuous supervision.
Two residents who were frequently incontinent and dependent on staff did not receive timely incontinence care, resulting in prolonged periods in soiled briefs and urine on the floor. Documentation was inconsistent, and staff interviews confirmed delays in care and failure to follow facility protocols for regular checks and assistance.
A resident with sleep apnea and edema received PRN oxygen therapy as ordered, but staff failed to document oxygen administration, tubing changes, or equipment cleaning as required by facility policy. Multiple staff confirmed the resident's regular oxygen use, yet no records were found in the MAR or TAR, and no maintenance schedule was in place.
A resident with chronic pain did not receive prescribed oxycodone on multiple occasions due to delays in obtaining a refill, stemming from communication issues between staff, the clinic, and the pharmacy. The resident reported difficulty with daily activities and refused showers until the medication was reordered. Staff confirmed attempts to refill the prescription in advance, but the process was not completed in time, resulting in missed doses.
A resident with diabetes who sometimes needed help with oral care lost their lower denture after placing it on the bedside table, possibly wrapped in a napkin. Despite staff searching for the denture, it was not found, and the resident was told they were responsible for replacement. The Administrator was not informed of the loss at the time, resulting in a delay in starting the replacement process.
A resident with nicotine dependency and visual impairment, who required staff supervision and a smoking apron, was provided with a visibly moldy apron due to a lack of clean equipment. Staff attempted to clean the apron with an alcohol-based wipe before use, but it still smelled of mold and alcohol. Multiple staff acknowledged the unsanitary condition of the apron and the infection control concern.
A resident with moderate cognitive impairment and on anticoagulant therapy was found with a large, unexplained bruise. Nursing staff documented the injury and initiated a risk management report, but did not notify the State Agency as required for suspected abuse or unexplained injuries.
A resident discharged after a stroke did not have therapy orders signed before leaving the facility, as the physician was unavailable. Although home health services were recommended, the lack of signed orders delayed the start of physical and occupational therapy until the resident saw their primary care physician after discharge.
The facility did not notify the state LTC Ombudsman of discharges for three residents, including individuals with diabetes, stroke, and heart failure, as required. Documentation and discharge forms did not include these residents, and staff confirmed the lack of notification.
The facility failed to maintain sanitary food handling practices. A Cook/Dietary Aide used the same gloves and cutting board after wiping it with a bleach rag, then handled food without changing gloves. The Dietary Manager confirmed that staff are expected to change gloves and use portable cutting boards.
The facility failed to ensure hygienically clean laundry by allowing wet laundry to remain in machines overnight and not rewashing it before drying. Housekeeping staff admitted to these practices, which were confirmed by the Housekeeping Manager.
The facility failed to ensure proper labeling and storage of biologicals and medications, and did not maintain accurate temperature logs for medication storage. Expired vials of tuberculin and insulin were found, and temperature logs were incomplete, placing residents at risk for reduced efficacy of medication and adverse side effects.
The facility failed to maintain clean resident rooms, as evidenced by a resident's room having visible dust and hairs under the bed despite being marked as cleaned. The housekeeping manager acknowledged the issue, and Resident Council notes indicated similar complaints from other residents.
A resident with major depressive disorder and anxiety was verbally abused by an RN who insisted the resident take a shower, making derogatory comments about their hygiene in front of others. The incident was corroborated by multiple staff and another resident, leading to the RN's termination.
A resident purchased a scrub top online for a CNA with the expectation of being reimbursed. The CNA paid only part of the amount owed, and the facility failed to provide documentation of reimbursement to the resident, leading to financial abuse.
A facility failed to provide necessary ROM services and equipment for a resident with contractures, leading to a lack of follow-up on OT recommendations and the resident not participating in a restorative aide program. The resident's condition was not adequately monitored or managed, placing them at risk of worsening contractures and skin breakdown.
A resident with weakness and heart failure fell from a sit-to-stand device due to untrained staff usage. The incident was not properly assessed, documented, or investigated, placing the resident at risk for injuries.
The facility failed to ensure proper oxygen administration and maintenance of oxygen concentrators for two residents. One resident's concentrator filter was not cleaned as ordered, and another resident received oxygen at an incorrect flow rate with a dirty filter.
The facility failed to follow pharmacist recommendations in a timely manner for a resident with major depressive disorder and psychosis. The pharmacist's suggestion to adjust medications was not reviewed and signed by the physician until 19 days later, contrary to the facility's 7-day policy, placing the resident at risk for unnecessary medication administration.
The facility failed to have a dialysis agreement in place for a resident dependent on renal dialysis. Upon request, the Corporate RN confirmed that no agreement was in place.
The facility failed to accurately document medication administration for a resident with hypothyroidism and septic arthritis. The resident's April 2024 MAR and TAR revealed missed documentation for levothyroxine and vancomycin doses. Staff confirmed the medications were administered but not documented, risking inaccurate medical records.
The facility failed to offer a pneumonia vaccine to a resident admitted with depression in August 2023, despite a policy requiring vaccination status assessments within five working days of admission. Staff confirmed the oversight, placing the resident at risk for infections.
Failure to Maintain Emergency Medication Supply and Timely Medication Administration
Penalty
Summary
The facility failed to maintain an on-hand supply of emergency hypoglycemic medication and did not administer anti-seizure medications according to provider orders for two residents. One resident with end stage kidney disease and Type I diabetes experienced multiple episodes of severe hypoglycemia, resulting in unresponsiveness and repeated hospitalizations. Despite standing physician orders for glucagon injections in cases of low blood glucose, the facility did not have glucagon available in the emergency kit or on medication carts. Staff confirmed the absence of glucagon, and documentation showed that during several hypoglycemic events, no glucagon was administered, and the resident was instead sent to the hospital for treatment. Another resident with quadriplegia and a traumatic brain injury did not receive anti-seizure and muscle relaxant medications at the times ordered. Medication administration records showed that doses of Baclofen, Levetiracetam, and Klonopin were given several hours late and in close proximity to each other, rather than being spaced out as prescribed. Staff involved in medication administration were unsure of the policy for late medications and did not contact the provider when errors occurred. There was no documentation in the resident's chart indicating that the provider was notified of the medication errors or that any alert charting was completed. Interviews with staff and review of records confirmed that the facility did not follow standing orders for diabetic management and failed to maintain sufficient emergency medication supplies. Additionally, the facility did not ensure timely and appropriate administration of anti-seizure medications, nor did staff seek guidance from the provider when medication errors occurred. These failures resulted in repeated hospitalizations and placed residents at risk for adverse health outcomes.
Failure to Provide Sufficient Nursing Staff Resulting in Delayed Call Light Responses
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in prolonged call light response times for multiple residents. Several residents, including those with cognitive impairment, mobility limitations, and incontinence, experienced significant delays in receiving assistance. For example, one resident with memory loss reported waiting approximately 30 minutes for staff to answer the call light on multiple occasions, as confirmed by call light logs and staff interviews. Staff acknowledged that busy times, such as mornings and mealtimes, contributed to delays, with some staff reporting that they could only assist one resident at a time while multiple call lights were active. Another resident with a femur fracture and requiring assistance with activities of daily living waited up to an hour for help with toileting, as documented in a grievance form and corroborated by staff. The resident reported being left on a bedpan for 20 to 30 minutes until the shift changed, and staff confirmed the resident's complaint. Additional residents with conditions such as respiratory failure, kidney disease, and recent fractures also experienced call light response times ranging from 25 minutes to over an hour, leading to episodes of incontinence and discomfort. Call light logs and resident statements consistently indicated that response times exceeded the facility's stated expectation of five to fifteen minutes. Staff interviews, including those with CNAs and the Director of Nursing Services, confirmed awareness of the delays and the expectation for timely responses. However, documentation and direct observation revealed that these expectations were not met, particularly during busy periods. The lack of adequate staffing and delayed responses placed residents at risk for unmet needs and compromised their ability to attain or maintain their highest practicable well-being.
Expired Medications Found in Storage and Carts
Penalty
Summary
Surveyors identified that the facility failed to ensure medications and biologicals were not expired in multiple storage locations, including the medication storage room, a medication cart, and a treatment cart. During observations, two bottles of Metamucil with an expiration date of 4/2025 were found in the medication storage room, and a bottle of acid reducer 20mg with an expiration date of 5/2025 was found on a medication cart. Additionally, two vials of insulin (Insulin Aspart and Insulin Glargine) with open dates of 7/17/25 were found on a treatment cart, exceeding the facility's policy to discard multi-dose vials within 28 days of opening. Staff interviews confirmed the expectation that expired medications should be destroyed and replaced, and that insulin vials should be discarded 28 days after opening. The Director of Nursing Services acknowledged the presence of expired medications in the storage room, medication cart, and treatment cart, and confirmed the facility's policy regarding the handling of expired medications and insulin vials.
Ice Machine Drain Lacks Required Air Gap
Penalty
Summary
Surveyors observed that the facility failed to maintain an air gap in the drainpipe of the kitchen ice machine, as required to prevent backflow and potential contamination. During two separate observations with the Dietary Manager, the ice machine drainpipe was found inserted directly into a drain hole without an air gap. The Dietary Manager confirmed the absence of flooding in the kitchen for years, but did not address the missing air gap. The Maintenance staff reported that the lack of an air gap had been identified in a work order in July 2025, but the issue was not corrected. The Administrator stated he was unaware of the missing air gap prior to the survey.
Failure to Follow Physician Orders for Medications, Insulin, and Tube Feedings
Penalty
Summary
The facility failed to ensure physician orders were followed for four residents in areas including medication administration, insulin management, and tube feedings. For one resident with heart failure, a fluid restriction was discontinued per physician order with instructions to reinstate it if certain symptoms occurred. However, the facility did not consistently monitor the resident for weight gain, edema, or breathing difficulties as required, and did not clarify with the physician whether monitoring parameters were still necessary after daily weights were discontinued. Another resident with end-stage kidney disease and Type I diabetes experienced multiple episodes of severe hypoglycemia and hospitalizations. The facility did not maintain standing orders for glucagon injections, failed to administer glucagon when blood glucose was critically low, and did not ensure glucagon was available in the emergency kit. Additionally, the facility did not follow through with physician orders to enroll the resident in a continuous glucose monitoring program, despite repeated recommendations and hospital discharge instructions. A third resident experienced medication errors when a provider order to decrease insulin dosage was not followed, resulting in the administration of an incorrect dose. The same resident also had a delay in the initiation of an antibiotic order. For a fourth resident with a feeding tube, a provider order for enteral nutrition was incorrectly discontinued, resulting in missed feedings over several days. In each case, staff acknowledged the errors and confirmed that provider orders were not double-checked for accuracy as expected.
Failure to Provide Correct Size Incontinence Products
Penalty
Summary
The facility failed to ensure that a resident with bowel and bladder incontinence consistently received the correct size of incontinence briefs as specified in the care plan. The resident, who was cognitively intact and had a diagnosis of diabetes, reported that the facility often ran out of the required three X size briefs, resulting in the use of smaller, uncomfortable briefs. Staff interviews confirmed that the resident's specific size was regularly back ordered, leading to periods of two to three days approximately every two weeks when the correct size was unavailable. Central Supplies staff acknowledged the ongoing supply issue, and Social Services staff confirmed the resident's complaints and the back order status. The administrator stated that the facility was responsible for ensuring adequate supplies for care-planned needs.
Failure to Notify Family of Resident Hospitalization
Penalty
Summary
The facility failed to notify a resident's family member of a hospitalization, as required. A resident admitted with diabetes experienced multiple episodes of low oxygen saturation, rapid pulse, and diarrhea, which did not improve with interventions, leading to a hospital transfer. The resident's clinical record listed a family member as the first emergency contact, but there was no documentation that this contact was notified of the hospitalization. The resident, who was cognitively intact, stated that her family should be contacted in such situations. The family member confirmed she was not notified and only learned of the hospitalization after the resident returned and called her. The Director of Nursing Services stated that staff did not notify family because the resident was her own responsible party.
Failure to Maintain Comprehensive Care Plan for Resident on Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure that a resident's care plan was comprehensive and accurately reflected all physician orders and the resident's needs. A resident with diagnoses including heart failure and pain was admitted and had a physician order for weekly skin checks and for administration of apixaban, an anticoagulant, twice daily. The resident's annual MDS indicated moderate cognitive impairment. On one occasion, a nurse was notified that the resident had a long, dark bruise on the underside of the right breast, which the resident could not explain and did not report pain. Staff confirmed that the resident was on anticoagulant therapy and bruised easily. Although the care plan noted anticoagulant therapy and directed staff to report and document abnormalities such as bruising, it was confirmed by the Director of Nursing Services that the physician order for anticoagulant medication was not included in the care plan. The care plan was not updated after the bruise was discovered, despite staff notification and risk management initiation.
Resident Left Unsupervised on Bedside Commode Despite Fall Risk
Penalty
Summary
A resident with a history of left leg fracture, anxiety, and difficulty walking was identified as high risk for falls upon admission. The care plan specified that the resident's call light should always be within reach and that the resident should not be left unsupervised in the bathroom or on the bedside commode. On the morning in question, the resident activated the call light while on the bedside commode, but staff did not respond for 21 minutes. During this time, the resident self-transferred back to bed, as confirmed by both the resident and staff observations. Further investigation revealed that the CNA who assisted the resident onto the bedside commode left to complete a shower for another resident and notified other staff by radio, but was unaware that the resident was not to be left alone on the commode. The Director of Nursing Services confirmed that the resident's care plan required supervision while on the bedside commode. This lapse in following the care plan resulted in the resident being left unsupervised, placing the resident at risk for accidents.
Failure to Provide Timely Incontinence Care for Dependent Residents
Penalty
Summary
The facility failed to provide timely incontinence care for two residents who were frequently incontinent and dependent on staff for assistance. One resident, admitted with kidney failure and muscle weakness, was cognitively intact and required help with toileting. Documentation showed inconsistent recording of incontinence care, with some shifts lacking documentation and no refusals noted. The resident reported that it was easier to wear a brief than wait for staff, and described an incident where they soaked through their wheelchair, leaving urine on the floor, due to not receiving timely assistance. Staff interviews confirmed that the resident remained in a soiled state between lunch and dinner without incontinence care, and staff acknowledged being busy and not providing care as scheduled. Another resident, admitted with benign prostatic hyperplasia and lower urinary symptoms, was also cognitively intact and required staff assistance for incontinence care. Documentation indicated inconsistent care and no refusals. A grievance was filed after the resident requested a brief change and did not receive assistance for an hour, resulting in the resident being soaked and urine present on the floor. Staff interviews corroborated the delay in care and the resident's complaint. Facility policy required staff to check on residents every two hours and offer assistance, but this was not consistently followed for these residents.
Failure to Document and Provide Safe Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for a resident with diagnoses including sleep apnea and edema. Although a physician ordered PRN oxygen therapy via nasal cannula for shortness of breath, there was no documentation of the start date, oxygen tubing changes, or cleaning of the oxygen concentrator filter. The facility's policy required detailed documentation for oxygen administration, but the Medication Administration Record (MAR) and Treatment Administration Record (TAR) contained no entries regarding the resident's PRN oxygen therapy during the review period. Multiple observations and interviews confirmed that the resident regularly used oxygen, including while sleeping and during various shifts. Staff and therapy personnel also reported the resident's reliance on oxygen. Despite this, there was no documentation of oxygen use or required maintenance procedures, and the Director of Nursing Services confirmed the absence of a tubing and filter cleaning schedule. This lack of documentation and adherence to policy placed the resident at risk for unmet respiratory needs.
Failure to Ensure Timely Refill of Pain Medication
Penalty
Summary
A resident with a diagnosis of chronic pain was admitted to the facility and had an order for oxycodone to be administered every eight hours as needed for pain. The resident's medication administration record (MAR) and order summary reports indicated that oxycodone was to be refilled by a specific physician. On several occasions, the resident did not receive the prescribed oxycodone due to issues with obtaining a timely refill. Progress notes documented that the pharmacy placed the medication on hold pending clarification of the prescribing physician, and staff were unable to use the emergency supply. As a result, the resident missed multiple doses of oxycodone. The resident expressed difficulty participating in daily activities and getting out of bed without the pain medication and refused showers until the medication was reordered. Staff interviews confirmed that attempts were made to refill the prescription at least a week in advance, but delays occurred due to communication issues with the clinic and pharmacy. The Director of Nursing Services acknowledged the need for a system to ensure timely medication refills. The failure to provide the prescribed pain medication as ordered resulted in the resident experiencing periods without adequate pain control.
Failure to Timely Replace Lost Denture
Penalty
Summary
A resident with diabetes was admitted to the facility and, according to their Activities of Daily Living (ADL) report, sometimes required assistance with oral care. The resident reported that the facility lost their lower denture after placing it on the bedside table, possibly wrapped in a napkin while applying adhesive. When the resident later attempted to eat a snack, the lower denture could not be found. Facility staff, including CNAs, searched the bedding, laundry, and dietary department but were unable to locate the missing denture. Documentation showed that the Director of Nursing Services (DNS) informed the resident they were responsible for the care of their dentures and would need to pay for a replacement. The Administrator stated they were not notified of the missing denture at the time it was lost, and as a result, the process to replace the denture was not initiated promptly. This failure to ensure timely replacement of the lost denture constituted a deficiency in providing or obtaining necessary dental services for the resident.
Failure to Provide Clean Smoking Equipment
Penalty
Summary
The facility failed to provide clean and sanitary smoking equipment for a resident who was admitted with nicotine dependency and visual impairment, and who required staff supervision and the use of a smoking apron while smoking. On the day of the incident, staff reported that no clean smoking aprons were available, and the only remaining apron was visibly moldy. Staff expressed reluctance to use the moldy apron but ultimately attempted to clean it with an alcohol-based wipe before placing it on the resident. The apron still smelled of mold and alcohol after cleaning, and staff acknowledged that residents should not be wearing moldy smoking aprons. The lack of clean equipment and the use of a moldy apron were confirmed by multiple staff members, including the Maintenance Director, as an infection control concern.
Failure to Report Bruise of Unknown Origin
Penalty
Summary
The facility failed to report a bruise of unknown origin for one resident who was on anticoagulant medication and had moderate cognitive impairment. The resident was admitted with diagnoses including heart failure and pain, and had physician orders for weekly skin checks and anticoagulant administration. On a specified date, a nurse was notified of a long, dark bruise on the underside of the resident's right breast, but the resident was unable to explain how the bruise occurred and did not complain of pain. There was no documentation indicating that staff notified the State Agency about the bruise. Staff confirmed that a risk management report was initiated, but the incident was not reported to the State Agency as required.
Failure to Ensure Timely Therapy Orders at Discharge
Penalty
Summary
A deficiency occurred when the facility failed to ensure that therapy orders were in place for a resident being discharged after a stroke. The resident was discharged according to the family's wishes, despite the therapy department recommending two additional weeks of therapy. Although a referral to a Home Health Agency was submitted, the necessary physical therapy and occupational therapy orders were not signed before discharge because the physician was not present in the facility. As a result, the home health provider did not receive the therapy orders until the resident visited their primary care physician after discharge, causing a delay in the initiation of home health therapy services.
Failure to Notify LTCO of Resident Discharges
Penalty
Summary
The facility failed to notify the state Long Term Care Ombudsman's office of discharges for three out of four sampled residents who were reviewed for discharges and hospitalizations. For one resident with diabetes, progress notes indicated a hospital admission, but there was no documentation that the LTCO was notified of the discharge. This was confirmed by the Regional Director of Quality Assurance. Another resident with a history of stroke was discharged, but the Ombudsman Notice of Residents Discharge form did not include this resident, and there was no documentation of LTCO notification, as verified by the same staff member. A third resident, admitted with acute respiratory failure with hypercapnia and chronic systolic heart failure, was also admitted to the hospital, but their name was not found on the Ombudsman Notice of Residents Discharge forms for the relevant months. The Social Services staff stated that a monthly fax was sent to the LTCO office listing all discharges, but no additional information was provided. Attempts to contact the LTCO office were unsuccessful, and the DNS stated that the LTCO office would be expected to be notified monthly for hospitalizations and immediately for deaths.
Failure to Maintain Sanitary Food Handling Practices
Penalty
Summary
The facility failed to handle and prepare food in a sanitary manner, as observed during a survey. Staff 26, a Cook/Dietary Aide, was seen cutting a hamburger patty with gloved hands on a cutting board attached to the steam table. After placing the patty on a plate, Staff 26 used a rag from a red bleach bucket to wipe the cutting board and knife, leaving the cutting board wet. Without changing gloves, Staff 26 then grabbed a skinned baked potato and cut it on the same wet cutting board with the same knife. When questioned, Staff 26 admitted to not knowing the appropriate drying time after wiping a surface and acknowledged forgetting to change gloves after using the rag. The Dietary Manager, Staff 27, stated that staff are expected to change gloves and perform hand hygiene after touching potentially contaminated surfaces and to use portable cutting boards, changing them as needed.
Failure to Maintain Hygienically Clean Laundry
Penalty
Summary
The facility failed to process laundry to produce hygienically clean laundry and prevent the spread of infection. Staff 22 and Staff 23, both from housekeeping, admitted to leaving wet laundry in the washing machine overnight and transferring it to the dryer the next morning without rewashing it. Additionally, Staff 23 mentioned placing damp laundry in a basket and covering it when the dryer cycle was not completed by the end of her shift, and then finishing the drying process the next morning. These practices were acknowledged by Staff 19, the Housekeeping Manager, who confirmed that the staff did not follow the standards required to produce hygienically clean laundry.
Failure to Ensure Proper Labeling and Storage of Medications
Penalty
Summary
The facility failed to ensure proper labeling and storage of biologicals and medications, as well as maintaining accurate temperature logs for medication storage. During an observation, two vials of tuberculin were found to be opened and expired, with one vial having an illegible date and the other dated beyond the manufacturer's recommended 30-day discard period. Staff acknowledged the expired vials. Additionally, the medication refrigerator temperature logs were found to be blank on several dates, indicating a failure to monitor and record the storage temperatures as required. Staff confirmed the missing temperature logs during the observation. Further observations revealed that the treatment cart for the 100 hall contained an expired Admelog insulin vial and an expired Novolog insulin vial, both of which were past the manufacturer's recommended 28-day usage period after opening. Staff acknowledged the expired insulin vials. These deficiencies in labeling, storage, and temperature logging placed residents at risk for reduced efficacy of medication and potential adverse side effects.
Failure to Maintain Clean Resident Rooms
Penalty
Summary
The facility failed to ensure resident rooms were cleaned adequately, as evidenced by the condition of one resident's room. Resident 9, who was admitted with diagnoses including respiratory failure and heart failure, had a room that was observed to have a visible layer of white and gray dust and hairs underneath the bed over a period of several days. Despite the Daily Cleaning Check-Off form indicating that the room was cleaned, the housekeeping manager acknowledged the presence of dust and deemed it unacceptable. Resident Council notes also indicated that residents had reported issues with dirty floors, further highlighting the deficiency in maintaining a clean environment.
Verbal Abuse of Resident by RN
Penalty
Summary
The facility failed to protect Resident 20 from verbal abuse by Staff 24 (RN). Resident 20, who was admitted with diagnoses including major depressive disorder and anxiety disorder, was cognitively intact and independent with bathing, requiring only setup help. On the morning of 3/31/24, Staff 24 approached Resident 20 about taking a shower, which the resident refused, stating they would shower after church. Staff 24 confronted Resident 20 again after church, insisting that the resident needed to shower because they 'stunk.' This confrontation occurred in front of other staff and residents, causing Resident 20 to feel upset and humiliated. Multiple staff members and another resident corroborated the incident, stating that Staff 24 yelled at Resident 20 and made derogatory comments about their hygiene. On 4/29/24, Resident 20 recounted the incident, stating that Staff 24's comments made them feel terrible. Staff 30, who was present during the second confrontation, confirmed that Resident 20 was visibly upset and crying after Staff 24 refused to leave the room. The facility's investigation, completed on 4/2/24, confirmed that Staff 24 had verbally abused Resident 20, leading to Staff 24's termination. Staff 2 (DNS) acknowledged the verbal abuse and confirmed the termination of Staff 24 following the investigation.
Misappropriation of Resident Funds by CNA
Penalty
Summary
The facility failed to ensure residents were free from misappropriation of personal funds by a CNA. Resident 302, who was alert and oriented, purchased a scrub top online for Staff 34 with the expectation of being reimbursed. Staff 34 paid only $20 of the $34 owed and continued to wear the scrub top, causing Resident 302 to feel disrespected. Despite the facility's assurance that Resident 302 would be reimbursed, there was no receipt or evidence of reimbursement provided to the resident. Interviews and record reviews revealed that Staff 34 was terminated, but the facility did not provide documentation of reimbursement to Resident 302. The Business Office Manager confirmed the absence of a receipt for the reimbursement, and the Corporate RN acknowledged the misappropriation of funds. The facility's policy stated that staff should not accept gifts or money from residents, yet this policy was not adhered to in this instance, leading to the financial abuse of Resident 302.
Failure to Provide ROM Services and Equipment for Resident with Contractures
Penalty
Summary
The facility failed to ensure that a resident with contractures received the necessary range of motion (ROM) services and equipment to prevent further decrease in ROM and skin breakdown. The resident, who was admitted with diagnoses including quadriplegia and rheumatoid arthritis, had a care plan from a previous facility indicating the use of palm protectors for contractures in both hands and legs. However, the current care plan did not include any mention of the resident's contractures or the use of a palm device. An occupational therapy (OT) evaluation recommended the use of a splint and ROM exercises, but no follow-up was conducted, and the resident did not receive the recommended care or participate in a restorative aide (RA) program after returning from the hospital. The resident expressed interest in wearing palm protectors and participating in the RA program, but no referral was made, and the resident's condition was not adequately monitored or managed by the facility staff. Observations revealed that the resident's hands were contracted, and no palm device was in use. Interviews with staff confirmed that the resident was not on the RA list, and no RA referral was completed. The OT evaluation was acknowledged but not acted upon, and the resident's fragile skin and contractures required extra monitoring that was not provided. The lack of follow-up and coordination among staff led to the resident not receiving the necessary ROM services and equipment, placing the resident at risk of worsening contractures and skin breakdown.
Failure to Assess and Prevent Falls
Penalty
Summary
The facility failed to assess falls and provide treatment to prevent falls for a resident admitted in 2022 with diagnoses including weakness and heart failure. The resident, who was cognitively intact, reported falling out of a sit-to-stand device several months prior. However, no fall assessments or incident reports were found in the clinical record. Staff 2 (DNS) initially denied the fall, stating the resident was assisted to the floor, and no assessment was completed. A written statement from Staff 20 (CNA) confirmed the incident but did not include the date. The resident and a family member both described the fall, indicating the resident fell to the floor and was later lifted back to bed using a mechanical lift. Staff 14 (Director of Rehab) acknowledged that only one staff member was trained to use the sit-to-stand device with the resident, but other untrained staff had used it during the incident. Further investigation revealed that Staff 21 (LPN) had started an incident report on the date of the fall but did not complete it, and it was later struck out by Staff 2 due to incorrect documentation. Staff 8, who was present during the fall, confirmed that the resident's legs became wobbly during the transfer, leading to the fall. Staff 2 admitted that the fall was not reported or investigated properly, and the involved staff did not receive appropriate training for using the sit-to-stand device with the resident. The lack of proper assessment, documentation, and training placed the resident at risk for falls and injuries.
Failure to Maintain Oxygen Therapy and Equipment
Penalty
Summary
The facility failed to ensure oxygen was administered as ordered and to maintain oxygen concentrators for two residents. Resident 36, admitted in August 2023 with chronic respiratory failure with hypercapnia, was observed using an oxygen concentrator with a dusty external filter from April 29, 2024, through May 1, 2024. Despite a physician's order to clean the filter every Tuesday night, the filter remained dirty. Staff 21, who was responsible for cleaning the filter, did not respond to a phone call, and Staff 2 acknowledged the filter was not clean. Resident 251, admitted in February 2024 with acute respiratory failure with hypoxia and dementia, was observed using an oxygen concentrator with a nasal cannula at a flow rate of three liters, contrary to the physician's order of one to two liters per minute as needed. The external filter on Resident 251's concentrator was also dusty, and the 4/2024 TAR did not specify when the filter should be cleaned. Staff 12 confirmed the resident used oxygen as needed, and Staff 2 acknowledged the physician's order was not followed and the filter was not clean.
Delayed Response to Pharmacist Recommendations
Penalty
Summary
The facility failed to follow pharmacist recommendations in a timely manner for a resident reviewed for unnecessary medications. The resident, admitted in 2023 with diagnoses including major depressive disorder and psychosis, had a pharmacist recommendation on 1/16/24 to adjust their medication regimen. The recommendation suggested increasing nortriptyline for depression and decreasing aripiprazole for psychosis. However, the physician did not review and sign off on the recommendation until 2/4/24, 19 days later. The facility's expectation was for such recommendations to be reviewed and signed within 7 days. This delay in addressing the pharmacist's recommendations was acknowledged by the Director of Nursing Services (DNS) and was not in compliance with the facility's policies, placing the resident at risk for unnecessary medication administration.
Lack of Dialysis Agreement for Resident
Penalty
Summary
The facility failed to have a dialysis agreement in place for a resident who was dependent on renal dialysis. The resident was admitted to the facility in April 2024. On April 30, 2024, a copy of the dialysis agreement was requested from the Corporate RN. Later that day, the Corporate RN confirmed that the facility did not have a dialysis agreement in place for the resident.
Failure to Accurately Document Medication Administration
Penalty
Summary
The facility failed to accurately document medication administration for a resident admitted in March 2024 with diagnoses including hypothyroidism and septic arthritis. A physician order dated April 1, 2024, instructed staff to administer one tablet of levothyroxine 50mcg daily at 5:00 AM. However, a review of the resident's April 2024 Medication Administration Record (MAR) revealed that the scheduled dose on April 26, 2024, was not documented as administered. Staff 3 (RNCM) confirmed that the documentation was inaccurate and that Staff 32 (LPN) had administered the medication but forgot to document it in the clinical record. Additionally, a physician order dated April 22, 2024, instructed staff to administer vancomycin solution 250 ml intravenously twice daily at 11:00 AM and 11:00 PM. A review of the resident's April 2024 Treatment Administration Record (TAR) showed that the scheduled dose on April 26, 2024, at 11:00 AM was not documented as administered. Staff 3 (RNCM) confirmed that the documentation was inaccurate and that Staff 33 (LPN) had administered the medication but forgot to document it in the clinical record. These documentation failures placed the resident at risk for inaccurate medical records.
Failure to Offer Pneumonia Vaccine
Penalty
Summary
The facility failed to ensure that residents were offered a pneumonia vaccine, as evidenced by the case of one resident who was admitted in August 2023 with a diagnosis of depression. A review of the resident's clinical record revealed that the resident did not receive a pneumonia vaccine and there was no indication that the vaccine was offered upon admission. The facility's policy, dated March 2022, required assessments of pneumococcal vaccination status within five working days of admission. However, this policy was not followed in the case of the resident. Staff confirmed that the resident was not offered the pneumonia vaccine upon admission, which placed the resident at risk for infections.
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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