Avamere Rehabilitation Of Junction City
Inspection history, citations, penalties and survey trends for this long-term care facility in Junction City, Oregon.
- Location
- 530 Birch Street, Junction City, Oregon 97448
- CMS Provider Number
- 385229
- Inspections on file
- 26
- Latest survey
- December 8, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Avamere Rehabilitation Of Junction City during CMS and state inspections, most recent first.
Two residents, one with chronic pain and another with Alzheimer's disease, were subjected to verbal abuse and derogatory remarks by another resident. Staff and the DNS confirmed the inappropriate behavior, which included profanity, name-calling, and offensive comments, but the facility failed to prevent or adequately address these incidents.
A resident with quadriplegia and neuropathic bladder experienced a traumatic Foley catheter placement, followed by infection and hospitalization. The facility did not thoroughly investigate the incident, as the staff member who performed the catheter change was not identified and no witness statement was obtained. Staff interviews revealed uncertainty about who completed the procedure, and the DNS confirmed that a witness statement should have been included.
A resident with dementia and dysphagia, care planned for total assistance and supervision during meals due to behavioral issues, was left unsupervised in the dining room, resulting in a verbal altercation with another resident. Staff interviews confirmed multiple occasions where no CNA was present during meals, despite the care plan requirement for supervision.
The facility did not ensure proper infection control in laundry services, as staff failed to separate soiled and clean linens, used a fabric gown multiple times before cleaning, and lacked training on PPE and disinfectant use. The workflow required staff to move through clean areas after handling soiled linen, and key information on disinfectant dwell times was not accessible.
A resident admitted with an unstageable pressure ulcer and pain was not accurately assessed, as the MDS failed to document the number of unstageable pressure ulcers and left relevant sections incomplete. Documentation did not reflect that the resident was receiving care for a pressure ulcer, and the DNS acknowledged the inaccuracy.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as observed and documented by surveyors.
A resident did not receive the necessary behavioral health care and services required to meet their needs, as the facility failed to provide appropriate behavioral health interventions and support.
Two residents did not receive their scheduled medications, including an antidiabetic and a movement disorder medication, because the drugs were not available at the time of administration. Staff reported that the medications had been ordered from the pharmacy but had not arrived, resulting in a medication error rate above 5%.
Staff did not deliver care or services that were trauma informed or culturally competent, failing to meet required standards for addressing residents' trauma histories or cultural needs.
Two residents in a LTC facility experienced significant medication errors. One resident received an incorrect dosage of apixaban, leading to a GI bleed and hospitalization. Another resident was mistakenly given another's medications, including antipsychotics and blood pressure meds, but showed no adverse effects. These incidents highlight lapses in medication administration protocols.
A resident with congestive heart failure gave $1200 to a CNA, who admitted to accepting the money despite knowing it was against facility rules. The resident intended $1000 as a loan and $200 as a gift, motivated by the CNA's financial struggles. The incident was reported by another staff member, leading to the CNA's termination.
The facility failed to ensure an RN was available for at least eight consecutive hours, seven days a week for 19 of 60 days reviewed. This deficiency was identified through a review of the facility's Direct Care Daily Staff Reports, and the Scheduling Coordinator acknowledged the lack of RN coverage on these dates, placing residents at risk for inadequate RN oversight and nursing assessments.
The facility failed to maintain appropriate medication storage temperatures for one medication storage refrigerator, which contained tuberculin, influenza vaccines, insulin, and an emergency medicine kit. The temperature logs revealed multiple instances of temperatures below the required range of 36-46 degrees F over a three-month period. Staff acknowledged the issue and stated that staff were expected to readjust the temperature, recheck it later, and contact management if temperatures were out of range.
The facility failed to store and handle food in a sanitary manner, with observations of unsealed freezer bags, expired food items, and undated condiments in two unit refrigerators and freezers. The Dietary Manager confirmed that expired items were not discarded.
The facility failed to follow CDC-recommended infection control standards for a resident with head lice. The resident was placed on Enhanced Barrier Precautions instead of contact precautions, and their personal items were not properly laundered or treated. Housekeeping staff did not follow correct PPE protocols, placing other residents at risk.
The facility failed to assist a resident with the formulation of an advance directive, despite the resident's request for assistance. The resident, admitted with depression and bipolar disorder, requested help in November 2023, but no assistance was provided as confirmed by the resident and staff.
The facility failed to maintain clean and functional equipment for two residents. One resident's walker had a loose wheel and worn handle, while another's wheelchair was dirty and had torn armrests. Both issues were acknowledged by staff but remained unaddressed, compromising the residents' environment.
A resident with vascular dementia and bipolar disorder was diagnosed with head lice, but the facility failed to update the care plan promptly. The diagnosis was made on April 2, 2024, and treatment was applied the same day, but the care plan was not updated until April 4, 2024. The DNS acknowledged the delay.
A resident with dementia and muscle weakness, who was moderately cognitively impaired, was found smoking unsupervised despite a care plan requiring supervision. The resident sustained a burn injury after receiving a cigarette from another resident and smoking it independently. The Director of Nursing Services acknowledged that the care plan was not followed.
Failure to Protect Residents from Verbal Abuse by Another Resident
Penalty
Summary
The facility failed to protect residents from verbal abuse by another resident, resulting in two residents being subjected to inappropriate and abusive language. One resident, who was cognitively intact and admitted with chronic pain and muscle weakness, reported that another resident entered their room, used profanity, and called them names. This resident also described a separate incident where the same individual made a derogatory comment while the resident was going to the shower. Staff confirmed that the abusive resident verbally attacked this resident and made fat jokes, and the Director of Nursing Services acknowledged the behavior as inappropriate. Another resident, admitted with Alzheimer's disease and a cognitive communication deficit, was also subjected to verbal abuse by the same resident. During an incident, staff overheard the abusive resident making derogatory statements, including saying that "you people need to go to fucking jail" and referring to others as "fucking crazies." Staff described the behavior as rude and verbally abusive, and the Director of Nursing Services confirmed the inappropriateness of the conduct. The facility did not prevent or adequately address these incidents, resulting in residents being exposed to verbal abuse.
Failure to Investigate Catheter-Related Injury
Penalty
Summary
The facility failed to thoroughly investigate a treatment-related injury involving a resident with quadriplegia and neuropathic bladder who experienced a traumatic Foley catheter placement. The resident was admitted with significant medical needs and was cognitively intact at the time of the incident. On the night the catheter was changed, the resident later developed symptoms of infection, including nausea and elevated temperature, and subsequently became nonresponsive, requiring emergency hospitalization for septic shock. The facility's investigation did not include documentation identifying the staff member who performed the catheter placement or a witness statement from that staff member. Interviews with staff revealed uncertainty about who completed the procedure, and attempts to contact the suspected staff member were unsuccessful. The Director of Nursing Services acknowledged that the investigation should have included a witness statement from the staff involved.
Failure to Provide Supervision During Meals for Resident with Behavioral Needs
Penalty
Summary
Staff failed to provide care and treatment as outlined in the care plan for a resident with dementia and dysphagia who required total assistance and supervision during meals. The care plan specified that the resident was to eat in a designated dining room under supervision due to an easy-chew diet and a history of behavioral issues, including agitation and verbal aggression. On one occasion, the resident and another individual engaged in a verbal altercation in the dining room, and it was confirmed that no CNA was present to supervise at the time, despite the care plan requirement. Multiple staff interviews revealed that there were several instances where no CNA was present in the dining room during meals, including during the incident involving the verbal altercation. Staff acknowledged that supervision was required for the resident's safety, but CNAs alternated supervision due to other responsibilities, leading to lapses in coverage. Facility leadership confirmed that staff should have been present to supervise the resident as outlined in the care plan.
Infection Control Deficiency in Laundry Services
Penalty
Summary
The facility failed to implement proper infection control standards in its laundry services, as evidenced by observations and staff interviews. Soiled and clean linens were not adequately separated, and staff did not consistently follow standard precautions. A fabric gown used for handling soiled linen was hung in the clean area next to washing machines, and staff would walk through the clean area to access the sink for handwashing after sorting soiled linen. The gown was only cleaned once daily despite being used multiple times a day. Staff were not provided with procedures for the use of personal protective equipment (PPE) in the laundry room, nor were they informed about the required dwell time for the disinfectant cleaner used in the area. Further, staff responsible for laundry services had not received training on handling biohazard waste or soiled linens, and there was a lack of clear guidance regarding the use and effectiveness of the disinfectant cleaner. The Housekeeping Manager acknowledged the need for increased training, and the Director of Nursing Services recognized that the workflow between clean and soiled areas in the laundry room was problematic. The expected information about disinfectant dwell times was not readily available to staff, contributing to improper infection control practices.
Inaccurate Assessment of Pressure Ulcer on Admission
Penalty
Summary
The facility failed to accurately assess a resident admitted with an unstageable pressure ulcer to the buttocks and pain. Upon review, the admission Minimum Data Set (MDS) indicated the resident was at risk for developing pressure ulcers and had one or more unhealed pressure ulcer injuries, but did not document the number of unstageable pressure ulcers due to non-removable dressings or devices. The section of the MDS addressing unstageable pressure ulcers present on admission or re-entry was left incomplete. Additionally, the skin and ulcer treatment section noted the use of a pressure reducing device and surgical wound care, but there was no documentation reflecting that the resident was receiving care for a pressure ulcer. The Director of Nursing Services acknowledged the inaccuracy of the MDS assessment.
Failure to Follow Physician Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of records, which indicated that care provided did not align with the established care plan or the expressed wishes and clinical needs of the resident involved.
Failure to Provide Necessary Behavioral Health Care and Services
Penalty
Summary
The facility failed to ensure that each resident received necessary behavioral health care and services. This deficiency was identified when it was observed that the facility did not provide the required behavioral health interventions or support to meet the needs of its residents, as mandated by regulations. The lack of appropriate behavioral health care and services was noted during the survey, indicating a failure to address residents' behavioral health requirements.
Medication Error Rate Exceeds Acceptable Threshold Due to Unavailable Medications
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as evidenced by two medication errors out of 25 observed medication administration opportunities, resulting in an 8 percent error rate. Specifically, one resident with diabetes and obesity did not receive their scheduled dose of Jardiance because the medication was not available, despite a physician's order for daily administration. Another resident with muscle weakness did not receive their prescribed Ingrezza for a movement disorder, also due to the medication not being available at the time of administration. In both cases, staff reported that the medications had been ordered from the pharmacy but had not yet arrived, leading to missed doses.
Failure to Provide Trauma-Informed and Culturally Competent Care
Penalty
Summary
The facility failed to provide care or services that were trauma informed and/or culturally competent. This deficiency indicates that staff did not consider or incorporate trauma-informed approaches or cultural competence into the care or services provided to residents, as required. The report does not specify the number of residents affected or provide additional details about their medical history or condition at the time of the deficiency.
Medication Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by two separate incidents involving residents. In the first case, a resident was readmitted to the facility with a diagnosis of pulmonary embolism and was prescribed apixaban, an anticoagulant medication. The physician's orders specified a dosage adjustment from 10 mg BID to 5 mg BID after six days. However, the facility failed to implement this dosage change, resulting in the resident receiving an excessive dose of apixaban for an extended period. This error was not identified until a nurse practitioner discovered it, by which time the resident had developed a gastrointestinal bleed, requiring hospitalization and a blood transfusion due to acute blood loss and anemia. In the second incident, a resident with a diagnosis of diabetes was mistakenly administered another resident's medications. The error occurred when a CMA, after being distracted by a request for assistance, inadvertently gave the wrong medications to the resident. The medications included several that the resident was not prescribed, such as antipsychotics and blood pressure medications. Although the resident was monitored and showed no significant adverse effects, the error highlighted a lapse in medication administration protocols. Both incidents underscore the facility's failure to adhere to proper medication administration procedures, resulting in significant medication errors. The first incident involved a failure to adjust medication dosages as per physician orders, leading to a serious health complication for the resident. The second incident involved a mix-up in medication administration, which, although not resulting in immediate harm, posed a potential risk to the resident's health. These deficiencies indicate a need for improved medication management and staff training to prevent future occurrences.
Misappropriation of Resident's Financial Resources
Penalty
Summary
The facility failed to protect a resident from financial exploitation, resulting in a deficiency related to the misappropriation of financial resources. A resident, who was admitted in 2022 with a diagnosis of congestive heart failure, gave $1200 to a CNA at the facility. The resident stated that $1000 was intended as a loan and $200 as a gift. The CNA, identified as Staff 3, admitted to discussing her financial difficulties with the resident and accepting the money, despite knowing it was against facility rules. The incident was reported by another staff member, Staff 5, who was informed by the resident about the transaction. Interviews revealed that Staff 3 was aware of the wrongdoing but felt compelled to accept the money due to her financial situation. The resident expressed a desire to help the CNA, who had mentioned her struggles with paying rent and having three small children. Staff 3 initially claimed to have refused the money but eventually accepted it after the resident insisted. The facility's investigation confirmed the misappropriation, and Staff 3 was subsequently terminated. The incident was reported to the Oregon Board of Nursing and law enforcement.
Failure to Ensure RN Coverage
Penalty
Summary
The facility failed to ensure a registered nurse (RN) was available for at least eight consecutive hours, seven days a week for 19 of 60 days reviewed. This deficiency was identified through a review of the facility's Direct Care Daily Staff Reports from February 1, 2024, through March 31, 2024. The specific dates without RN coverage were February 3, 4, 10, 11, 17, 18, 24, 25, and March 2, 3, 9, 10, 16, 17, 23, 24, 29, 30, and 31. On April 5, 2024, the Scheduling Coordinator acknowledged the lack of RN coverage on these dates, which placed residents at risk for inadequate RN oversight and nursing assessments.
Failure to Maintain Appropriate Medication Storage Temperatures
Penalty
Summary
The facility failed to ensure appropriate medication storage temperatures were maintained within parameters for one medication storage refrigerator. The refrigerator, which contained tuberculin, influenza vaccines, insulin, and an emergency medicine kit, was observed to have temperatures below the required range of 36-46 degrees F on 19 occasions between January 1, 2024, and April 2, 2024. The temperature logs indicated that the temperatures were to be checked twice daily, but the logs revealed multiple instances of temperatures below 36 degrees F. Staff 2 acknowledged the issue and stated that staff were expected to readjust the temperature, recheck it later, and contact management if temperatures were out of range, as cold temperatures could reduce the efficacy of insulin and vaccines.
Failure to Store and Handle Food Safely
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in two unit refrigerators and freezers. Observations revealed unsealed freezer bags of waffles, expired applesauce cups, ice cream with visible freezer burn, and undated or expired condiments and dairy products. The Dietary Manager acknowledged these observations and confirmed that the expired food items were not discarded as required.
Failure to Follow Infection Control Standards for Head Lice
Penalty
Summary
The facility failed to ensure appropriate infection control standards for a resident diagnosed with head lice. The resident, who was admitted with vascular dementia and bipolar disorder, was found to have live head lice. Despite receiving treatment, the resident was placed on Enhanced Barrier Precautions instead of the CDC-recommended contact precautions. Observations revealed that the resident continued to wear a fabric hat and leather jacket, which were not appropriately laundered or treated as per CDC guidelines. Additionally, housekeeping staff were observed entering the resident's room without following the correct PPE protocols for contact precautions. The Infection Preventionist and Director of Nursing Services acknowledged that the facility did not follow CDC recommendations for managing head lice. The resident's laundry and linens were washed with other residents' items, and the leather jacket and fabric hat were not properly treated. This failure to adhere to infection control standards placed other residents at risk for head lice infestation.
Failure to Assist Resident with Advance Directive
Penalty
Summary
The facility failed to assist Resident 10 with the formulation of an advance directive, despite the resident's request for assistance. Resident 10, who was admitted in January 2021 with diagnoses including depression and bipolar disorder, requested help from facility staff to establish an advance directive during a Comprehensive Plan of Care Review in November 2023. However, a review of the resident's clinical record from November 2023 through April 2024 revealed no indication that the facility staff provided the requested assistance. This was confirmed by Resident 10 on April 1, 2024, and acknowledged by Staff 13 on April 2, 2024.
Failure to Maintain Clean and Functional Resident Equipment
Penalty
Summary
The facility failed to ensure resident equipment was clean and in good repair for two residents. Resident 22, who was readmitted with diagnoses including dementia and muscle weakness, was observed using a walker with a loose front wheel and a worn handle missing foam. Despite the resident's statement that the physical therapist was aware of the issues, the walker remained unrepaired. The occupational therapist confirmed the need for repairs, and the administrator acknowledged the deficiencies, including non-functional brakes on the walker. Resident 14, admitted with multiple sclerosis, was observed using a wheelchair that was dirty with dried food debris and had torn armrests exposing the metal underneath. A CNA noted the dirty condition of the wheelchair days prior and was informed that the night shift was responsible for cleaning it. The administrator confirmed the observations of the dirty and damaged wheelchair. These deficiencies placed residents at risk for living in an unhomelike environment.
Failure to Timely Update Care Plan for Head Lice
Penalty
Summary
The facility failed to update the care plan for a resident diagnosed with head lice in a timely manner. The resident, who was admitted in February 2024 with vascular dementia and bipolar disorder, was found to have live head lice on April 2, 2024. The resident's provider was notified, and treatment was prescribed and applied the same day. Despite this, the resident's comprehensive care plan did not include information about the head lice diagnosis until April 4, 2024. The Director of Nursing Services acknowledged that the care plan was not updated promptly.
Failure to Ensure Supervised Smoking
Penalty
Summary
The facility failed to ensure supervision and safety interventions were in place to prevent smoking-related accidents for a resident with a history of dementia and muscle weakness. The resident, who was moderately cognitively impaired, had a documented history of smoking in the building, burning herself/himself, and not following smoking rules. Despite the care plan indicating that the resident was to smoke only under supervision and that tobacco and fire materials were to be stored by the facility, the resident was found smoking unsupervised in the courtyard with another resident. This incident resulted in the resident singeing her/his hair and sustaining a burn mark above her/his right eye. On the day of the incident, staff observed the resident smoking unsupervised and noted the burn injury. The resident admitted to receiving a cigarette from another resident and smoking it independently. Staff found several cigarette butts and a pack of cigarettes in the resident's possession. The burn on the resident's forehead was treated and resolved by the following day. The Director of Nursing Services acknowledged that the resident's care plan for supervised smoking was not followed, leading to the incident where the resident burned herself/himself.
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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