Avamere Rehabilitation Of King City
Inspection history, citations, penalties and survey trends for this long-term care facility in Tigard, Oregon.
- Location
- 16485 Sw Pacific Highway, Tigard, Oregon 97224
- CMS Provider Number
- 385132
- Inspections on file
- 21
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Avamere Rehabilitation Of King City during CMS and state inspections, most recent first.
A resident with multiple sclerosis, opioid use, and chronic pain, who was cognitively intact, experienced very low blood pressure and altered responsiveness during a night shift. A CNA noted the resident’s unusually deep sleep and lack of response during incontinence care and alerted an LPN, who confirmed low BP and later called the provider and 911. EMS records showed the resident was found altered earlier than the call time, and Narcan administration improved vital signs before hospital transfer, where the resident was treated for septic shock due to UTI and related complications. Facility policy required comprehensive baseline assessment and documentation of vital signs, neuro status, pain, level of consciousness, and onset/severity of condition, but the progress notes contained only limited information, and the Administrator acknowledged a delay in response and incomplete documentation.
A resident with multiple sclerosis, diabetes, and opioid use had a PRN order for naloxone (Narcan) nasal spray to be given in both nostrils for decreased responsiveness. During a surveyor observation of the emergency kit, only IV Narcan was found instead of the ordered nasal formulation. The facility Administrator confirmed that the correct nasal route Narcan was not available for this resident.
The facility experienced significant staffing shortages, particularly for CNAs, from September to December 2024, leading to unmet care needs for residents. Resident Council notes and public complaints highlighted issues such as long call light response times and missed showers. Several residents, including those requiring substantial assistance, were directly affected, with staff confirming that evening and night shifts often ran short-staffed, resulting in incomplete ADL tasks.
The facility experienced significant staffing shortages, particularly with CNAs, leading to unmet care needs for residents. Many residents required extensive assistance, but persistent staffing issues resulted in long call light response times and delays in essential care. Complaints highlighted the impact on resident care, including missed showers and inadequate supervision during meals. The administrator acknowledged the staffing challenges, which were documented through interviews and call light tracking sheets.
Three residents in a LTC facility did not receive person-centered activities as per their care plans, leading to a deficiency. One resident with major depressive disorder and dementia was not engaged in any activities, despite a care plan including music and pet therapy. Another resident, speaking Farsi/Arabic, had no documented activity participation, and staff failed to provide necessary resources. A third resident, speaking Vietnamese, also lacked engagement in activities, with staff not utilizing translation services. The Activities Director confirmed the lack of documentation and activities.
The facility failed to properly label and store beverages and bulk food items, risking foodborne illness. A scoop was improperly stored in bulk sugar, and opened juice containers in a refrigerator had unclear labeling, leading to potential spoilage. Staff were unclear on monitoring responsibilities.
A facility failed to implement a care plan for a resident with dysphagia, who required upright positioning during meals to prevent aspiration. Despite the care plan's directive, the resident was observed eating in bed with the head-of-bed elevated only to 45 degrees. Staff were unaware of the required positioning, leading to the resident's difficulty in eating and food spillage.
A resident with dementia, whose preferred language is Vietnamese, was not provided an interpreter during cognition assessments, leading to inaccurate evaluations. Despite documentation indicating the need for an interpreter, staff conducted assessments in English, resulting in the resident feeling misunderstood. The DNS acknowledged the expectation for staff to use translators during such interactions.
A facility failed to complete a Level I PASARR screening for a resident admitted with stroke and schizophrenia. The resident's electronic health record showed no evidence of the required screening prior to admission, and staff confirmed the absence of the screening.
The facility failed to update care plans for two residents, leading to potential unmet needs. One resident, initially requiring assistance with eating, was observed to eat independently, yet the care plan was not revised. Another resident required mobility bars for bed mobility and fall prevention, but the care plan lacked interventions for their use. Staff confirmed these discrepancies, highlighting the need for accurate care plan updates.
A resident with dementia and a preferred language of Vietnamese did not receive appropriate communication services at the facility. Despite a care plan indicating the need for a translator and translation service, staff did not utilize these resources, leading to ineffective communication. Staff were unaware of the resident's language needs, and interactions were conducted in English, which the resident struggled to understand.
A resident with dementia did not receive their prescribed lidocaine 4% pain patch on multiple occasions due to a failure in the supply ordering process. The Maintenance Director, who was newly responsible for ordering supplies, did not order the patches in time, leading to their unavailability. This resulted in the resident not receiving the medication as per the physician's orders.
The facility failed to provide necessary restorative services and equipment for two residents with limited mobility, leading to potential risks of further decline. One resident did not receive the prescribed hand splint for hemiplegia, and staff were unaware of its necessity. Another resident, requiring restorative therapy for stroke-related impairments, received fewer sessions than ordered due to staff being reassigned to CNA duties. Despite these deficiencies, no decline in functional abilities was documented.
A resident with dysphagia and no teeth was served beef fajitas, which did not meet the facility's guidelines for an easy-to-chew diet. The resident struggled to eat the meal, and staff later confirmed the food was not appropriate for the resident's dietary needs. A CNA was unaware of the resident's risk for aspiration, highlighting a lack of adherence to dietary requirements.
The facility failed to assist two residents with ADLs, leading to unmet needs. A resident with cognitive impairment was not assisted with shaving despite expressing a desire for hair removal. Another resident requiring two staff for bed baths was not bathed as scheduled, reportedly due to staffing shortages. The DNS acknowledged the issue but could not confirm resolution.
Failure to Timely Respond and Document Resident Change of Condition
Penalty
Summary
The deficiency involves staff failure to respond timely and completely to a resident’s change of condition and to document required baseline assessment data. The facility’s Acute Condition Changes-Clinical Protocol, revised 3/2018, required nurses to assess and document/report baseline information including vital signs, neurological status, current pain level, level of consciousness, and onset, duration, and severity of the condition. Resident 4, who had multiple sclerosis, opioid use, and chronic pain, was cognitively intact per a Quarterly MDS with a BIMS score of 15. On 11/25/25, a Blood Pressure Summary Report showed the resident’s blood pressure was 86/53 at 5:00 AM as taken by an LPN (Staff 6). A progress note at 6:50 AM documented the blood pressure as 70/50, and that Staff 6 called the provider and 911, but no additional assessment information was recorded. Interviews and external records showed that staff recognized abnormal findings and altered responsiveness but did not promptly act or fully document the change of condition. A CNA (Staff 14) reported that during the night the resident appeared to be sleeping, and at 5:00 AM the resident’s blood pressure was very low, prompting her to alert Staff 6. Staff 14 and Staff 6 provided incontinence care and noted it was unusual that the resident did not wake up during care and did not respond, despite typically waking when laid flat. Staff 6 stated the resident was unable to be awakened and had an abnormally low blood pressure, after which she called the provider and then 911. A Fire and Rescue Public Incident Report documented that the facility reported the resident was found with altered mental status at 5:00 AM, with EMS called at 6:46 AM and arrival at 6:50 AM, when Narcan was administered and vital signs improved. A subsequent hospital discharge summary documented admission for septic shock due to UTI, acute kidney injury, acute metabolic encephalopathy, and acute hypoxic/hypercapnic respiratory failure. The Administrator (Staff 1) acknowledged there was a delay in staff response to the change of condition and that the progress notes lacked the required baseline information.
Failure to Stock Correct Route of Ordered Emergency Narcan
Penalty
Summary
Surveyors found that the facility failed to provide the correct route of administration for an ordered emergency opioid antidote medication. A resident who was re-admitted in 12/2025 with multiple sclerosis, diabetes, and opioid use had a physician’s order dated 11/2025 for naloxone HCL (Narcan) nasal liquid 4 mg/0.1 mL to be administered in both nostrils as needed for decreased responsiveness. During an observation of the facility’s emergency kit on 2/19/26 at 12:34 PM, surveyors identified that Narcan was stocked only in an intravenous (IV) form rather than the prescribed nasal route for this resident. On 2/20/26 at 2:46 PM, the Administrator acknowledged that the facility did not have the correct nasal route formulation of Narcan available for the resident. This deficiency reflects the facility’s failure to obtain and maintain the ordered nasal formulation of naloxone in its emergency supply for a resident with an active PRN order for nasal Narcan for decreased responsiveness, as confirmed by observation of the emergency kit contents and staff acknowledgment.
Staffing Shortages Lead to Unmet Resident Care Needs
Penalty
Summary
The facility failed to ensure sufficient nursing staff was available to meet the needs of residents, leading to unmet care needs. The facility's staffing policy from October 2019 indicated an ongoing review of resident acuity to ensure adequate staffing. However, from September to December 2024, the facility was understaffed for CNAs on 39 out of 116 days, failing to meet state minimum staffing requirements. Resident Council notes from this period highlighted concerns about call light wait times, deactivated call lights without care, and delays in food tray removal, particularly in the 300 Hall, which required heavy care. Multiple public complaints were received by the State Agency, alleging short staffing of CNAs, resulting in long call light response times, unmet basic care needs, and increased resident anxiety and agitation. Specific incidents on September 28, October 6, October 7, December 24, and December 26, 2024, were reported, with residents not receiving showers and experiencing long call light response times. Staff interviews confirmed that evening and night shifts often ran short-staffed, leading to incomplete ADL tasks and missed showers. Several residents were directly affected by the staffing shortages. Resident 6, admitted in 2019, required substantial assistance with showering and did not receive a scheduled shower on December 26, 2024, due to staffing shortages. Similarly, Resident 15, admitted in June 2024, missed scheduled showers due to staffing issues, going seven days between showers on two occasions. Resident 10, admitted in 2014, also missed a scheduled shower on December 24, 2024, due to understaffing. Staff confirmed that showers were not provided to any residents on that day, and the facility's expectation was to offer showers as scheduled or the next day if missed due to staffing issues.
Staffing Shortages Lead to Unmet Resident Needs
Penalty
Summary
The facility failed to ensure sufficient nursing staff was available to meet the needs of its residents, as evidenced by multiple complaints and interviews. The facility had a census of 62 residents, with a significant number requiring extensive assistance for daily activities such as bathing, toileting, and dressing. Despite these needs, the facility was consistently short-staffed, particularly with CNAs, leading to unmet care needs. Residents reported long call light response times, sometimes waiting over 30 minutes for assistance, which resulted in delays in toileting and other essential care. Numerous complaints were filed with the State Agency, highlighting the persistent staffing shortages across all shifts, with the evening and night shifts being particularly affected. These shortages led to residents not receiving timely showers, inadequate supervision during meals, and increased fall risks. Witnesses and staff confirmed the ongoing staffing issues, noting that the facility was often short by three to four CNAs, which compromised the quality of care provided to residents. Specific residents, such as those admitted with conditions like fractured hips and strokes, experienced significant delays in call light responses, sometimes up to an hour. These delays were documented in call light tracking sheets, showing response times frequently exceeding the facility's target of 15 minutes. The administrator acknowledged the staffing challenges and the impact on care delivery, indicating an awareness of the issues but a struggle to maintain adequate staffing levels.
Failure to Provide Person-Centered Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing person-centered activity program for three residents, leading to a deficiency in meeting their psychosocial and quality of life needs. Resident 9, admitted with major depressive disorder and dementia, had a care plan that included activities such as music, pet therapy, and religious services. However, observations revealed that Resident 9 was not engaged in any activities, and there was no documentation of participation in the activity logs or electronic health records. Staff interviews confirmed the lack of one-on-one activities and the absence of documentation. Resident 24, who spoke Farsi/Arabic and had dementia, also did not participate in any documented activities despite having a care plan that included social visits and self-directed activities. Observations showed that Resident 24 was often in their room with the television on mute and no materials for activities. Staff attempts to provide an iPad for Arabic channels were unsuccessful, and no one-on-one activities were observed. The Activities Director confirmed the lack of documentation and activities for Resident 24. Resident 47, who spoke Vietnamese and had dementia, was similarly affected. The resident's care plan included preferences for group activities and outdoor time, but there was no evidence of participation in any activities. Observations showed the resident in their room or dining area with no engagement in activities. Staff interviews revealed a lack of awareness of the resident's activity interests and the absence of translation services during interactions. The Activities Director acknowledged the failure to document activities and the need to update the resident's care plan.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to ensure proper labeling and storage of beverages and bulk food items, which could lead to foodborne illness. During an inspection of the kitchen's dry storage area, a plastic scoop was found partially buried in bulk sugar, which staff acknowledged was not stored appropriately. The scoop should have been placed in a holster above the sugar to minimize the risk of cross-contamination. Additionally, in the snack refrigerator located in the facility's 100 hallway, several previously-opened liter containers of nectar-thick lemon water and orange juice were found with unclear labeling. The dates on the containers did not specify whether they referred to the opening date or the discard date. Staff acknowledged that these items should be discarded as it was unsafe to store and use juice beyond seven days after opening. There was also a lack of clarity among staff regarding who was responsible for monitoring and discarding outdated items in the refrigerator.
Failure to Implement Nutritional Care Plan for Resident with Dysphagia
Penalty
Summary
The facility failed to implement care plan interventions for a resident with dysphagia, placing them at risk for unmet nutritional needs. The resident, admitted in December 2016, was identified as having short-and-long-term memory loss, moderate impairment in decision-making, and was edentulous. The care plan required the resident to be positioned upright at 75 to 90 degrees during meals to prevent aspiration. However, observations on multiple occasions revealed the resident eating in bed with the head-of-bed elevated only to approximately 45 degrees. Staff members, including CNAs and the Resident Care Coordinator, were unaware or did not ensure the correct positioning during mealtimes, as evidenced by the resident's difficulty in eating and food spillage.
Failure to Use Interpreter for Cognition Assessment
Penalty
Summary
The facility failed to accurately assess a resident's cognition due to not utilizing an interpreter, despite the resident's preferred language being Vietnamese and the need for an interpreter being documented. The resident, who was admitted with a diagnosis of dementia, had multiple MDS assessments indicating the need for an interpreter to communicate effectively. However, these assessments were conducted without an interpreter, and the BIMS interview was not attempted as the resident was noted to be rarely or never understood. Observations and interviews revealed that the resident felt misunderstood at the facility. The Social Services Director admitted to completing a staff assessment without a translator, and another staff member was unaware of the resident's preference for an interpreter, conducting all MDS interviews in English. The DNS acknowledged these findings and stated that staff were expected to use a translator during interactions with the resident, especially for MDS interviews.
Failure to Complete Level I PASARR Screening
Penalty
Summary
The facility failed to ensure a Level I PASARR (Preadmission Screening for Individuals with a Mental Disorder and Individuals with Intellectual Disability) was completed for a resident reviewed for PASARR. The resident was admitted in June 2023 with diagnoses including stroke and schizophrenia, a mental disorder. A review of the resident's electronic health record revealed no evidence that a Level I PASARR screening was completed prior to admission. On July 17, 2024, staff members confirmed they were unable to locate the required screening for the resident.
Care Plan Deficiencies for ADLs and Fall Prevention
Penalty
Summary
The facility failed to ensure care plans were revised to accurately reflect the needs of two residents, leading to potential risks for unmet needs. Resident 45, admitted with diagnoses including stroke and schizophrenia, was observed to eat meals independently, contrary to the care plan which indicated a need for one-person assistance. Staff confirmed that Resident 45 was independent with eating, yet the care plan was not updated to reflect this change in the resident's level of functioning. Resident 48, admitted with osteomyelitis and muscle weakness, required bilateral mobility bars for bed mobility and fall prevention, as indicated by a fall investigation and physician order. However, the care plan did not include interventions for the use of these mobility bars, despite observations confirming their presence on the resident's bed. The Director of Nursing Services acknowledged the care plan's failure to reflect the resident's current needs for bed mobility and fall prevention.
Failure to Provide Adequate Communication Services for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide appropriate communication services for a resident whose preferred language was Vietnamese. Despite the resident's care plan indicating the need for a translator and the use of an iPad translation service, staff members did not utilize these resources. Instead, they relied on asking yes or no questions, which the resident often answered affirmatively, regardless of understanding. This lack of effective communication tools and strategies led to the resident feeling misunderstood and unable to express their preferences or interests. Staff members were unaware of the resident's language needs, with some mistakenly believing the resident spoke other languages such as Taiwanese or Cantonese. The Social Services Director conducted check-ins exclusively in English, which the resident struggled to understand due to dementia. The Director of Nursing Services acknowledged the communication care plan was unclear, contributing to the deficiency in providing adequate communication support for the resident.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure physician orders were followed for a resident who was prescribed a lidocaine 4% pain patch for pain management. The resident, diagnosed with dementia, was to have the patch applied to the lower back once daily, with it being on for 12 hours and off for 12 hours. However, the Medication Administration Record (MAR) for July 2024 indicated that the patch was not administered according to the physician's orders on several days. Staff 7, a Certified Medication Aide (CMA), reported that there were no lidocaine patches available on one of the days, preventing her from administering the medication. Staff 8, the Maintenance Director, was responsible for ordering the patches but failed to do so in a timely manner due to unfamiliarity with the ordering system, as this was a new task for him. The facility's Administrator acknowledged that Staff 8 had recently taken over the responsibility of ordering supplies and was not yet familiar with the process, which contributed to the oversight.
Failure to Provide Restorative Services for Residents with Limited Mobility
Penalty
Summary
The facility failed to provide appropriate restorative services and equipment to prevent further decline in range of motion for two residents with limited mobility. Resident 10, who was admitted with hemiplegia and hemiparesis following a stroke, was observed without the prescribed right hand splint, which was intended to assist with her/his upper extremity impairment. Staff members, including CNAs, were unaware of the resident's need for a splint, and there was no evidence of a comprehensive assessment, ongoing monitoring, or a care plan addressing the resident's impairment. The DNS and Resident Care Coordinator acknowledged the lack of assessments and monitoring, and uncertainty about the appropriateness of the hand splint. Resident 25, admitted with a history of falls and stroke-related hemiplegia and hemiparesis, was supposed to receive restorative therapy three times a week as part of a care plan to prevent functional decline. However, the resident reported receiving therapy only once a week on average. Documentation showed that out of 13 to 22 ordered sessions, only nine therapy sessions were conducted, with one resident refusal. Staff indicated that restorative therapy staff were frequently reassigned to CNA duties, impacting the delivery of therapy sessions. Despite the missed sessions, there was no documentation of a decline in the resident's functional abilities.
Failure to Provide Appropriate Diet Texture for Resident with Dysphagia
Penalty
Summary
The facility failed to ensure that the appropriate diet texture was followed for a resident with dysphagia, placing them at risk for choking. The resident, who was admitted in December 2016, had diagnoses including dysphagia and was edentulous. According to the facility's guidelines, a regular, easy-to-chew diet should consist of foods that break apart easily and pass the fork pressure test. However, during an observation, the resident was served beef fajitas, which did not meet these criteria. The resident struggled to bite through the tortilla, causing the contents to spill, and attempted to eat large pieces of beef, which were not easy to chew. Staff interviews revealed a lack of awareness regarding the resident's dietary needs. A CNA believed the resident was not at risk for aspiration and was on a regular diet. During a subsequent observation with the DNS and Resident Care Coordinator, it was confirmed that the meat served was not easy to chew, contradicting the resident's dietary requirements. The staff acknowledged that beef fajitas and tortillas were not considered easy-to-chew foods, indicating a failure to adhere to the prescribed diet texture for the resident.
Failure to Assist Residents with ADLs Due to Staffing Issues
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents, leading to unmet needs and potential loss of dignity. Resident 19, admitted with severe cognitive impairment and requiring substantial assistance for personal hygiene, was observed over several days with facial hair that she/he expressed a desire to have removed. Despite this, staff members, including a CNA and an LPN, confirmed that they had not been instructed to assist with shaving, and the resident's request for hair removal was not fulfilled. Resident 28, with normal cognitive function and requiring assistance from two staff members for bed baths, was documented to have refused multiple bed baths over several months. However, the resident stated that she/he had only refused two baths and was informed by CNAs that baths could not be provided due to staffing shortages. The DNS confirmed that missed showers and bed baths were a problem, potentially due to staffing levels, but could not confirm if the issue had been resolved.
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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