Avamere Rehabilitation Of Hillsboro
Inspection history, citations, penalties and survey trends for this long-term care facility in Hillsboro, Oregon.
- Location
- 650 Se Oak Street, Hillsboro, Oregon 97123
- CMS Provider Number
- 385251
- Inspections on file
- 22
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Avamere Rehabilitation Of Hillsboro during CMS and state inspections, most recent first.
Two residents did not receive care according to physician orders and facility protocols. One resident on an antidepressant with constipation risk went six days without a bowel movement; although Senna and MiraLAX were ordered per the bowel protocol, they were not administered, and only a suppository was given on the sixth day, contrary to the stepwise bowel regimen. Another resident with an amputation and multiple wounds had lubricant eye drops ordered twice daily and PRN for dry eyes, but the drops were not given for an extended period due to a transcription error, resulting in at least 28 missed doses. The same resident also had ordered wound care to the right leg and chest that was not performed on certain days when the resident was in conferences or meetings, with TAR entries indicating treatment was held and no documentation that the wound care was completed, despite the expectation that physician orders be followed.
A resident with a history of hip and femur fractures, identified as a high fall risk and requiring a two-person transfer with a Hoyer lift, was transferred by a CNA without assistance and without the lift. This resulted in the resident falling from the bed and sustaining a right distal femur fracture.
The facility failed to provide accessible overbed lights and television remotes for three residents, affecting their independence. A resident with chronic kidney disease was without a TV remote for over a month, while two other residents could not reach their overbed light cords. Staff acknowledged the need for accessibility, but the issues remained unresolved.
The facility failed to maintain accurate records for four residents, including discrepancies in care plans and incomplete vaccine consent forms. A resident with Huntington's disease had an inaccurate care plan regarding meal supervision, while three other residents had missing information on their vaccine consent forms, such as ID numbers and physician details. Staff interviews confirmed these deficiencies.
A resident with Huntington's disease requested a personal computer to meet psychosocial needs, but the facility failed to assist in purchasing it despite available funds. The resident, who was cognitively intact, expressed feeling cut off due to the lack of a computer. Staff and the administrator confirmed the oversight.
The facility failed to provide SNF ABN notifications to two residents who remained in the facility after their Medicare Part A benefits ended. This oversight was confirmed by the Social Services Director and acknowledged by the Administrator, placing residents at risk of unknown financial liabilities.
A resident with anemia and chronic kidney disease reported missing clothing and a personalized blanket, filing grievances with staff assistance. Despite the facility's policy to protect residents' items, the grievances remained unresolved, leading to the resident using donated clothing. The facility's administrator acknowledged the unresolved issue, highlighting a failure to follow up on grievances.
A facility failed to provide a person-centered activities program for a hospice resident with alcoholic cirrhosis. The resident, who valued activities like reading and music, was observed without access to these resources and did not participate in group activities. Staff interviews revealed a lack of awareness and training regarding the resident's needs, and the Activity Director admitted the care plan was not comprehensive. The resident's cognitive decline and increased dependency required more support, which was not provided.
A resident at moderate risk for falls exited a facility through an emergency exit door with a non-functioning alarm, resulting in a fall outside. The facility failed to investigate the environmental factors contributing to the incident, and the resident's care plan lacked clarity regarding bed height, leading to inconsistencies in its implementation.
The facility failed to maintain respiratory equipment for two residents, leading to potential respiratory concerns. A resident with chronic respiratory failure required continuous oxygen, and another with COPD used oxygen PRN. Both had oxygen concentrators with dusty filters, and staff confirmed the lack of a cleaning schedule.
A resident with Huntington's disease and major depressive disorder did not receive a trauma assessment as required by the facility's policy. Despite expressing feelings of depression and a willingness to discuss trauma history, the resident's needs were not addressed. Staff confirmed the oversight, and the facility administrator acknowledged the findings.
A resident with Huntington's disease and depression did not receive necessary behavioral health care. Despite moderate depression scores, no specific mood interventions were provided. The resident felt unsupported, and staff struggled to address emotional needs. The care plan was confusing, and interactions were limited to passive activities. The administrator acknowledged the need for improvement.
A resident admitted with gastroenteritis and colitis did not receive ordered physical and occupational therapy services due to oversight after multiple hospital stays. Despite physician orders, therapy evaluations were not conducted, and services were not resumed, leading to a decline in the resident's functional abilities.
The facility failed to notify the Ombudsman when two residents were transferred to the hospital. One resident, admitted with hypertrophic pyloric stenosis, was hospitalized for shortness of breath and fluid retention. Another resident, admitted with pneumonitis, was hospitalized multiple times for serious conditions, including a pulmonary embolism and sepsis. The facility lacked a process to notify the Ombudsman, as acknowledged by the administrator.
The facility failed to honor the rights of three residents to refuse room transfers. Despite residents' refusals to sign room move notifications, the facility proceeded with the moves, citing the need to condense rooms for new admissions and a misunderstanding of state regulations. The residents involved had various medical conditions, including anemia, respiratory failure, congestive heart failure, stroke, coronary artery disease, and urinary tract infections.
A resident with severe cognitive impairment and a history of walking around the facility eloped after being left unsupervised. The resident was found later at a hospital after being reported missing. Staff interviews revealed the resident had previously attempted to leave the facility but was usually redirected. On the day of the incident, the resident was not under direct supervision, and staff were unaware of the resident's whereabouts until it was too late.
Failure to Follow Bowel Protocol and Physician Orders for Eye and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its bowel care protocol and physician orders for bowel management and eye lubrication, resulting in missed treatments for two residents. For one resident with hypothyroidism, breast cancer, and depression, the care plan identified constipation as a side effect of an antidepressant. The facility’s 2025 bowel care protocol required a stepwise approach to constipation, including administration of Senna after 3 days without a bowel movement, MiraLAX after 4 days, a suppository after 5 days, and an enema after 6 days. The resident’s MAR showed that although Senna and MiraLAX were prescribed, neither was administered during a 6‑day period without a bowel movement from 11/7/25 to 11/13/25, and only a suppository was given on the sixth day. Nursing staff confirmed that suppositories were intended to be used after other bowel interventions failed and that this sequence did not follow the facility’s bowel care protocol, and a CMA reported being unaware of the protocol. The deficiency also includes failures to follow physician orders for eye drops and wound care for another resident with an infected amputation stump, an open wound on the right thigh, acute posthemorrhagic anemia, and an above‑knee amputation. A physician order required lubricant eye drops twice daily and as needed for dry eyes, but the MAR showed the drops were not administered for a 16‑day period, and an LPN/Resident Care Manager stated the order had been transcribed incorrectly and that the resident missed at least 28 doses, placing the resident at risk for discomfort related to dry eyes. Additional physician orders required wound care to the resident’s right leg twice daily, then once each day shift, and daily chest wound care. On specific dates, the TAR reflected a code to hold treatment or see a nurse note, and progress notes documented a care conference or a meeting with social services, with no documentation that the ordered wound care was completed on those days. The LPN involved stated she did not complete the wound care when the resident was in these meetings, and the DNS stated that physician orders were to be followed.
Failure to Follow Transfer Protocol Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when staff failed to implement care plan interventions designed to prevent falls for a resident with a history of right hip and femur fractures. The resident was identified as a high fall risk and required a two-person transfer using a Hoyer lift, as documented in the care plan. Despite these interventions, a certified nursing assistant (CNA) attempted to transfer the resident from a wheelchair to bed without the required assistance and without using the Hoyer lift. During this transfer, the resident slid from the edge of the bed, twisted their ankle, and fell onto their right knee. As a result of the fall, the resident sustained a right distal femur fracture and required hospital evaluation. Facility records and staff interviews confirmed that the CNA did not follow the resident's care plan, which directly led to the accident and injury. The facility's investigation determined that the failure to adhere to the prescribed transfer protocol resulted in the resident's fall and subsequent fracture.
Inaccessible Overbed Lights and TV Remotes
Penalty
Summary
The facility failed to ensure that overbed lights and television remotes were accessible for three residents, which compromised their independence. Resident 6, admitted with chronic kidney disease, was cognitively intact but dependent on staff for transfers. The resident had been without a television remote for over a month, requiring assistance to change channels or turn the television on or off. Despite reporting the missing remote to staff, no action was taken, leading to frustration and a loss of independence for the resident. Staff members were unaware of the issue, and the Maintenance Director was not informed about the missing remote. Residents 362 and 364 also faced accessibility issues with their overbed lights. Resident 362, admitted with pneumonitis, could not reach the overbed light cord, which was only 3 inches long. Similarly, Resident 364, admitted with severe protein-calorie malnutrition, had an overbed light cord that was 11 inches long and out of reach. Staff acknowledged that residents should be able to operate their lights independently, and the Maintenance Director confirmed that cords should be at least 24 inches long to ensure accessibility. The Administrator confirmed that the cords should be long enough to drape on the bed for resident access.
Inaccurate Resident Records and Incomplete Vaccine Consent Forms
Penalty
Summary
The facility failed to ensure the accuracy of resident records for four out of five sampled residents, specifically regarding vaccination records. Resident 31, who was admitted with Huntington's disease, had discrepancies in their care plan related to meal supervision. Observations and staff interviews revealed inconsistencies between the care plan and the actual supervision provided during meal times. Staff members provided conflicting information about the level of supervision required, and it was acknowledged by the facility's administration that the care plan was inaccurate. Additionally, the facility did not maintain complete and accurate vaccine consent forms for Residents 6, 35, and 363. The consent forms were missing critical information such as ID numbers, nursing care center details, addresses, physician information, and dates of signatures. Staff interviews confirmed that the expectation was for these forms to be fully completed and dated before vaccine administration. The Director of Nursing Services confirmed the deficiency in the completion of these forms, which is a requirement for proper documentation and resident care.
Failure to Honor Resident's Request for Personal Computer
Penalty
Summary
The facility failed to honor a resident's request for a personal computer, which was necessary to meet the resident's psychosocial and activity needs. Resident 31, who was admitted in December 2019 with Huntington's disease, requested a personal computer during a care conference on December 3, 2024. The resident was cognitively intact and had the financial means to purchase the computer, as confirmed by a social service note and the resident's representative payee, who loaded funds onto the resident's Visa card on December 4, 2024. Despite the availability of funds and the resident's clear request, the facility did not assist in purchasing the computer. On January 21, 2025, the resident confirmed that they had not received the computer and expressed feelings of being cut off. Staff members acknowledged the request and the availability of funds but confirmed that the computer had not been purchased. The facility administrator also acknowledged the failure to assist the resident in acquiring the computer.
Failure to Provide SNF ABN Notifications
Penalty
Summary
The facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) notifications to two residents who were reviewed for Beneficiary Notification. Resident 12 was admitted with Medicare Part A benefits, and the facility's records indicated that the last covered day for Medicare Part A services was 11/1/24. However, the resident remained in the facility without receiving the required SNF ABN notification to inform them or their representative of potential out-of-pocket expenses. Staff 12, the Social Services Director, confirmed that the facility did not issue SNF ABN notifications to residents when they were discharged from Medicare Part A services and remained in the facility. Similarly, Resident 48 was admitted with Medicare Part A benefits, and the facility's records showed that the last covered day for Medicare Part A services was 10/28/24. Like Resident 12, Resident 48 remained in the facility without receiving the necessary SNF ABN notification. Staff 12 confirmed this oversight, and Staff 1, the Administrator, acknowledged that the facility did not issue SNF ABN notifications to residents and their representatives as required. This failure placed residents and their representatives at risk for lack of knowledge regarding their right to appeal and unknown financial liabilities.
Failure to Resolve Resident Grievance on Missing Personal Property
Penalty
Summary
The facility failed to address a grievance related to personal property for a resident, identified as Resident 38, who was admitted with anemia and chronic kidney disease. The resident, who was cognitively intact, reported missing several clothing items and a personalized blanket received as a birthday gift. Despite filing grievances with the assistance of staff, the items remained unresolved, leading to the resident running out of clothing and having to use items from the donated rack in the laundry. Staff interviews revealed that the resident had submitted Lost or Damaged Items forms several months prior, specifically on 9/19/24, for the missing items. However, the items were neither located nor replaced. The facility's administrator acknowledged the unresolved grievance and stated that it was expected that grievances should be followed up with the resident and family for an agreeable resolution. This lack of resolution placed residents at risk for unresolved grievances, as the facility did not adhere to its policy of protecting residents' items from theft or loss.
Failure to Provide Person-Centered Activities for Hospice Resident
Penalty
Summary
The facility failed to provide an ongoing person-centered activities program for a resident who was admitted with alcoholic cirrhosis of the liver and was on hospice care. The resident's Admission MDS indicated that activities such as reading, listening to music, and participating in religious services were important. However, observations and interviews revealed that the resident did not receive one-to-one visits, did not have access to their computer, music, or newspapers, and did not participate in group activities. The resident expressed a desire to engage in activities but was unable to do so due to a lack of support and resources. Staff interviews indicated a lack of awareness and training regarding the resident's activity interests and needs, particularly for those on hospice care. The Activity Director acknowledged that the resident's care plan was not comprehensive and that the resident was not included in activities such as Bible study, which they had expressed interest in. The staff also noted the resident's cognitive decline and increased dependency, which required more support to engage in activities. The facility's failure to update the resident's care plan and provide appropriate activities contributed to the deficiency.
Failure to Ensure Safe Environment and Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure a safe environment and implement care plan interventions to prevent falls for a resident, leading to a deficiency. The resident, who was admitted with alcoholic cirrhosis and ascites, was identified as being at moderate risk for falls. Despite this, the resident was able to exit the facility through an emergency exit door that did not have a functioning alarm, resulting in a fall outside the facility. The staff member assigned to the resident noticed the door was not completely closed and found the resident outside, having sustained minor injuries. The investigation revealed that the emergency exit door alarm was not functioning, and there was no evidence of a thorough investigation into the environmental factors contributing to the resident's elopement and fall. The facility's Code Pink Policy referenced a Door Alarm Policy that did not exist, and the Maintenance Director was unaware that the door required a working alarm. The Administrator confirmed that the door was not investigated following the incident, which should have been done. Additionally, the resident's care plan directed that the bed be at an appropriate height, but observations showed inconsistencies in the bed's height when the resident was in bed. Staff members were unclear about the care plan's instructions, with some believing the bed should be in the lowest position when occupied due to the resident's fall history. The Administrator and other staff acknowledged the care plan's lack of clarity regarding the bed's position.
Failure to Maintain Respiratory Equipment
Penalty
Summary
The facility failed to maintain respiratory equipment for two residents, leading to potential respiratory concerns. Resident 9, admitted with chronic respiratory failure and a fracture, required continuous oxygen. On observation, the oxygen concentrator's external foam filter was found with a thick layer of dust, and the resident expressed concern about its cleanliness. Staff acknowledged the dirty filter, and it was revealed that the facility lacked a cleaning schedule for the oxygen concentrators. Similarly, Resident 10, admitted with chronic obstructive pulmonary disease and cellulitis, required PRN oxygen use. The oxygen concentrator for this resident also had a dusty foam filter, and the resident used the concentrator as needed. Staff confirmed the filter's condition and the absence of a cleaning schedule for the equipment.
Failure to Conduct Trauma Assessment for Resident
Penalty
Summary
The facility failed to identify and address a resident's past history of trauma and potential triggers for re-traumatization, as required by their Trauma-Informed Care and Culturally Competent Care Policy. This policy mandates universal screening of residents for possible exposure to traumatic events, including trauma history and related symptoms, to inform individualized care plans. However, it was found that Resident 31, who was admitted in December 2019 with Huntington's disease and major depressive disorder, had not received such a trauma assessment. The resident expressed feelings of depression and noted that no one at the facility had discussed their trauma history or potential triggers with them. Observations and interviews with staff confirmed the deficiency. On two separate occasions, Resident 31 was observed expressing feelings of depression and a willingness to discuss their trauma history. Staff 29, an RN, noted that the resident's mood varied and they had outbursts. Staff 12 from Social Services confirmed that all residents were supposed to receive a trauma assessment and acknowledged that Resident 31 had not received one. The facility administrator, Staff 1, acknowledged the findings but did not provide additional information.
Failure to Provide Behavioral Health Care for Resident with Depression
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with Huntington's disease, major depressive disorder, and anxiety. The resident's PHQ-9 scores indicated moderate depression over several months, yet there was no evidence of specific mood interventions being offered. The resident expressed feeling generally depressed and not being offered the opportunity to talk to someone about their depression. Staff interviews revealed inconsistencies in addressing the resident's emotional needs, with social services staff unable to identify specific interventions following increased depression scores. The resident's care plan for psychosocial well-being was found to be confusing, and staff had difficulty understanding the resident due to slurred speech. The activity director's interactions with the resident were limited to dropping off puzzles and newspapers, with no active engagement in addressing psychosocial well-being. The facility administrator acknowledged the findings and recognized the need for improvement in the resident's care plans.
Failure to Provide Ordered Therapy Services
Penalty
Summary
The facility failed to provide physical and occupational therapy services as ordered for a resident, leading to a deficiency in care. The resident, who was admitted with diagnoses including gastroenteritis and colitis, had physician orders for physical therapy (PT) and occupational therapy (OT) as indicated. However, the resident's quarterly MDS indicated that no PT or OT services were provided during the review period. Staff interviews revealed that the resident was motivated and had been doing well with ambulation before multiple hospital stays, but therapy services were not resumed upon readmission to the facility. The Rehab Director acknowledged that despite the physician orders, evaluations and therapies were not initiated due to the resident's frequent hospitalizations. The physician expressed an expectation that therapy orders would be communicated and evaluations completed as ordered. The Director of Nursing Services and Regional Nurse Consultant admitted that the resident was overlooked, and the necessary evaluations were not conducted. The facility administrator also stated that it was expected for residents to be evaluated for PT and OT per physician orders upon admission or readmission, which did not occur in this case.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman when residents were transferred to the hospital, as required. This deficiency was identified for two residents who were hospitalized multiple times. Resident 60, admitted in November 2024 with hypertrophic pyloric stenosis, was sent to the hospital on November 13, 2024, for shortness of breath and fluid retention. A review of Resident 60's clinical record showed no evidence that the Ombudsman was notified of the transfer. Similarly, Resident 40, admitted in October 2024 with pneumonitis, was hospitalized on several occasions for various serious conditions, including a pulmonary embolism and sepsis. Despite these multiple hospitalizations, there was no indication in Resident 40's medical records that the Ombudsman was informed of any of these transfers. The facility's administrator acknowledged the requirement to notify the Ombudsman but admitted that the facility lacked a process to implement this requirement.
Failure to Honor Residents' Right to Refuse Room Transfers
Penalty
Summary
The facility failed to honor the rights of residents to refuse room transfers, affecting three residents who were part of a sample review for residents' rights. Resident 5, admitted with anemia and respiratory failure, was moved to a different room despite refusing to sign the room move notification. The move was justified by the facility as necessary due to the transition from skilled services to ICF services. Staff acknowledged that Resident 5 refused to sign the notification, but the move proceeded after a seven-day notice was provided. Similarly, Resident 7, with diagnoses of congestive heart failure and stroke, and Resident 19, with coronary artery disease and a urinary tract infection, were also moved to different rooms against their wishes. Both residents refused to sign the room move notifications, citing their desire to remain in their current rooms. Staff confirmed that room moves were discussed in meetings, and despite residents' refusals, the moves were executed based on the facility's interpretation of state regulations, which they believed required only notification of the move, not resident consent.
Failure to Evaluate Elopement Risks Leads to Resident Elopement
Penalty
Summary
The facility failed to evaluate elopement risks for a resident with severe cognitive impairment, leading to an unsafe elopement incident. The resident, diagnosed with dementia, was admitted in August 2022 and had a history of walking around the facility. On July 26, 2024, the resident was reported missing after being last seen in the dining room. Staff members were engaged in other tasks, and the resident was not immediately noticed missing. The resident was later found by a passerby and taken to a nearby hospital's emergency department after falling, but fortunately, sustained no serious injuries. Interviews with staff revealed that the resident was known to enjoy walking and had previously attempted to leave the facility, although they were usually redirected by staff. On the day of the incident, the resident was not under direct supervision, and staff were unaware of the resident's whereabouts until it was too late. The resident had been on 15-minute checks, but this was the first time the assigned CNA was responsible for the resident. The lack of a comprehensive elopement risk evaluation and adequate supervision contributed to the resident's ability to leave the facility unnoticed.
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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