Avamere Rehabilitation Of Lebanon
Inspection history, citations, penalties and survey trends for this long-term care facility in Lebanon, Oregon.
- Location
- 350 S. 8th, Lebanon, Oregon 97355
- CMS Provider Number
- 385168
- Inspections on file
- 25
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Avamere Rehabilitation Of Lebanon during CMS and state inspections, most recent first.
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.
A resident admitted with diabetes and a documented non-pressure chronic ulcer on the left foot had an ulcer and scabs on multiple toes and the top of the foot noted on admission assessments, and an MDS later confirmed a non-pressure chronic ulcer. However, no physician orders or wound treatments for the left foot ulcer were present in the clinical record for an extended period after admission, until nursing staff eventually messaged the physician and initiated treatment. An agency LPN could not recall confirming wound care orders at admission and stated that usual practice would be to contact the physician if orders were missing, and a regional nurse stated that staff should ensure physician orders exist for residents with skin wounds.
The facility did not involve staff or residents in determining staffing needs during its assessment, resulting in identified insufficiencies in staffing, training, and personnel. Interviews with a CNA, an LPN, and members of the Resident Council confirmed that input was not solicited and concerns about staffing and training were not addressed. No documentation was available to show that feedback or staffing data were incorporated into the assessment.
Surveyors found that staff failed to follow infection control protocols during a COVID-19 outbreak, including leaving used COVID-19 tests in open areas, not performing required hand hygiene, and not adhering to proper PPE use and signage. A resident with chronic respiratory illness was on special droplet precautions, but staff did not consistently follow posted guidelines or infection prevention policies.
The facility did not review resident rights during Resident Council meetings, as confirmed by both the Activity Director and Resident Council members. The Administrator acknowledged that resident rights were expected to be reviewed at these meetings, but this was not done.
The facility did not provide required written bed-hold notifications to residents or their representatives and failed to notify the LTC Ombudsman during transfers to hospitals and discharges home. This deficiency was confirmed for four residents with conditions such as heart failure, kidney disease, stroke, and alcohol abuse, with staff interviews and record reviews showing that these notifications were not completed as required.
Surveyors observed uncovered exterior refuse containers at multiple exits, each containing food debris and trash. Staff confirmed the lack of available lids, and facility leadership acknowledged the issue with uncovered refuse containers at several exterior doors.
A resident with chronic kidney disease and several recent hospitalizations did not receive a timely comprehensive assessment, as required. The annual MDS assessment was overdue, and there was no documentation of a significant change or admissions assessment after the resident's hospital returns. Facility staff acknowledged the delay and incomplete assessment.
A resident with a persistent vegetative state and traumatic brain injury did not receive timely referrals for PT, OT, SLP, or a neurologist as requested by family and indicated in the care plan. Staff were unclear about the referral process, and the resident's communication needs were not adequately assessed or addressed, resulting in delayed access to appropriate communication services.
A resident admitted with a leg fracture did not receive wound care as ordered by the orthopedic physician because the order was not entered into the TAR. The dressing was not removed or changed as directed, and staff did not assess the incision despite the resident's reports of pain. The omission led to the resident developing an incision infection, which was confirmed by staff interviews and record review.
A resident with a history of inhalant dependence and dementia was allowed to access and use smoking materials outside of designated areas and scheduled times, contrary to their care plan. Staff did not consistently secure smoking items in a lock box or monitor the resident as required, and the resident was observed leaving smoking materials unattended at the nurse's station and smoking independently outside the designated area.
Annual performance reviews were not completed for two CNA staff, as required. Personnel records indicated that the last evaluations for these staff members were not conducted within the expected annual timeframe, and the administrator confirmed the expectation for timely evaluations.
A resident with anxiety and heart failure exhibited new physically aggressive behavior, including banging a walker against the wall, which was not timely reported or documented by staff. Despite ongoing behavioral issues and ineffective interventions, key staff were unaware of the incident, and behavioral health staffing was noted as insufficient.
Treatment carts containing medications and medical supplies, including insulin, syringes, and antibiotics, were found unlocked and unattended in two hallways. Staff and residents were observed passing by the unsecured carts, and staff confirmed that carts are expected to be locked when unattended.
A resident with chronic kidney disease did not receive appropriate follow-up for dental services, despite facility policy requiring social services to coordinate and document such care. Although a dental referral was made, there was no evidence of a follow-up appointment or further action, and the Social Services Director could not provide documentation of any subsequent steps taken.
A resident dependent on staff for bathing, with diagnoses including COPD and metabolic encephalopathy, did not consistently receive scheduled showers as required by their care plan. Documentation showed missed showers on several scheduled days, with no evidence that additional opportunities were offered or refusals recorded. Staff interviews confirmed that blank logs indicated care was not provided, and one missed shower was attributed to short staffing.
The facility did not provide enough CNAs to meet required staffing ratios on multiple occasions, leading to missed showers, delayed bedtimes, and incomplete oral care for residents with significant care needs. Staff and residents reported frequent shortages, lack of management assistance, and continued admissions despite inadequate staffing, resulting in unmet resident needs and dissatisfaction.
A resident with diabetes, who was cognitively intact, reported missing money from their wallet. Staff investigated and ruled out theft due to inconsistent statements, offering to secure the remaining funds. However, the resident was not informed in a timely manner about the resolution or reimbursement, and staff failed to communicate the outcome as required by the facility's grievance policy.
A resident, who was cognitively intact and had a history of stroke, reported their cell phone missing after leaving it on their bedside table. Staff confirmed the resident had the phone the previous evening, and a search did not recover it. The phone was later located several blocks from the facility, indicating it had been taken. The facility failed to prevent the wrongful use or theft of the resident's belongings.
A resident with moderate cognitive impairment and dementia was subjected to a shirt change by a CNA despite repeatedly refusing the care and requesting to be left alone. The resident became visibly upset and distressed during the incident, which was witnessed and reported by other staff, and later confirmed by facility leadership as a failure to honor resident rights.
The facility failed to provide physician-ordered diets for three residents, leading to health risks. A resident with severe dysphagia was given incorrect food texture, causing a severe coughing episode. Another resident choked on inadequately prepared food, requiring emergency care. A third resident was served inappropriate food, leading to coughing. Staff were aware of errors but did not correct them due to a busy kitchen.
The facility failed to maintain proper meal temperatures and flavors, affecting food palatability and safety. A resident with malnutrition and diabetes reported consistently cold and bland meals, confirmed by staff observations. Sample plates during a lunch service were found to have cold, underdone, and unappetizing food.
The facility did not follow established recipes for meal preparation, as observed in the kitchen. A cook, employed for three weeks, reported not receiving recipes during training and did not follow any for lunch preparation. The Certified Dietary Manager confirmed that a new menu system with recipes was introduced, and they should have been followed for all therapeutic diets, risking residents' meal satisfaction and nutrition.
The facility did not monitor chemical concentration levels in the low-temperature dishwasher, risking improper sanitation. Staff were not instructed to check these levels, and the monitoring form lacked a section for documenting them. The Dietary Services Manager relied on monthly inspections instead of daily checks.
The facility failed to provide adequate staffing, resulting in long wait times for resident assistance, particularly during night shifts. Residents reported waiting up to 45 minutes for toileting help, leading to incontinence issues. Staff confirmed frequent CNA shortages and burnout, impacting their ability to complete care tasks. The administration acknowledged the staffing challenges.
The facility did not maintain RN coverage for eight consecutive hours per day on 34 out of 126 days reviewed, risking unmet assessment needs for residents. This issue was identified through staff daily report reviews, and facility leadership acknowledged the deficiency, noting the termination of two RNs.
The facility failed to post accurate staffing information, with multiple instances of missing LPN and CNA hours on the Direct Care Staff Daily Report (DCSDR). Staff were instructed to fill in numbers without hours, expecting administration to complete the form later. This issue was acknowledged by the Administrator and other staff members.
The facility did not ensure CNAs received the required 12 hours of annual in-service training, as shown by records for five staff members. One CNA had only 15 minutes of training in a year. Facility leaders admitted that training sign-up sheets were not collected, preventing proper tracking of training hours, which risked resident care due to insufficiently trained staff.
The facility failed to maintain a clean and homelike environment for several residents, with observations of flooring damage, unclean bathrooms, and hallway stains. Residents with various medical conditions were affected, and the Maintenance Lead confirmed the need for repairs.
A facility failed to address a pest infestation, leading to flies and maggots in resident areas. A resident with diabetes and a foot ulcer was found with maggots on their bed, traced to their wound dressing, and was hospitalized. Despite a work order for flies, the issue was not addressed promptly, and pest control arrived days later. The resident returned to find flies still present, and the room required multiple cleanings. An investigation revealed the facility was unaware of the initial work order, placing residents at risk.
A resident with PTSD and anxiety was harassed by another resident, who repeatedly intimidated them by staring and following them to their room. Despite complaints and staff observations, the facility failed to take effective action to protect the resident, resulting in increased anxiety and feelings of being unsafe.
A resident with PTSD and anxiety disorder reported feeling harassed by another resident, who frequently visited their hall and room, causing fear and anxiety. Despite staff observations and reports, management failed to investigate or protect the resident, instructing staff to redirect the harassing resident, which proved ineffective.
The facility failed to revise care plans for three residents, leading to unmet needs. A resident with a broken arm was at risk for contracture, but the care plan lacked documentation. Another resident with aphasia and stroke had a care plan for ADL deficits and nutritional issues but lacked details on eating assistance. A third resident with alcohol dependency and narcissistic personality disorder was not care planned for alcohol dependency or worsening behaviors with alcohol consumption. Staff confirmed these deficiencies.
The facility failed to provide timely assistance with ADLs for three residents, leading to unmet needs. A resident experienced a delay in toileting assistance, resulting in an incontinent episode. Another resident missed several showers due to time constraints, leading to body odor, while a third resident received fewer showers than scheduled due to staffing shortages. Staff acknowledged the issues and the need for improved training.
A resident with dementia and depression was not provided with timely replacement of broken hearing aids, despite a care plan indicating their necessity for addressing a mild hearing deficit. Observations showed the resident without hearing aids, and staff confirmed they had been broken for months. The Social Service Director was unaware of the issue, believing the resident chose not to wear them.
The facility failed to prevent accidents and respond to condition changes in a timely manner. A resident with a leg fracture experienced a fall and delayed care due to inadequate communication with the on-call physician. Another resident, requiring two staff for transfers, fell during a solo transfer attempt by a CNA, resulting in a hospital visit.
A resident with a nephrostomy tube experienced inadequate care due to unclear staff responsibilities, lack of training, and supply issues, leading to concerns about bag placement and incidents of leakage. The care plan lacked specific interventions, and there were no orders for nephrostomy care for a period of time.
The facility failed to obtain necessary oxygen orders for two residents with COPD, leading to unmet respiratory needs. One resident used oxygen almost daily without a formal order, while another had continuous oxygen use without documentation of prescribed LPM or tubing changes. Staff confirmed these practices, highlighting a lack of proper documentation and adherence to physician orders.
The facility failed to complete an annual performance review for a CNA hired in 2021, with the only review dated in 2022. This oversight was acknowledged by the facility's leadership during an interview, attributing the missed review to a staffing transition, potentially risking resident care due to lack of competent staff.
A facility failed to provide risk and benefit information related to antipsychotic medication to a resident's responsible party before administration. The resident, with moderate cognitive impairment, was prescribed Haloperidol for anxiety and agitation. The consent form was signed after the medication was already administered, contrary to facility protocol.
A care conference for a resident with dementia was not conducted as scheduled, and no rescheduling was communicated. A family member inquired about the conference, and staff confirmed the resident's absence and lack of concerns from the family. Staff acknowledged the need for the resident, family, and IDT to be present at such conferences.
A resident with diabetes and a foot ulcer was not consulted about changes to their shower schedule following a room move, which conflicted with their medical appointments. The LPN acknowledged that the schedule should have been discussed with the resident beforehand.
A resident with diabetes refused multiple CBG checks and orthostatic blood pressure assessments over several months. Despite physician orders for these checks, the facility did not notify the provider of the refusals, as confirmed by a regional nurse consultant.
The facility did not provide meaningful activities for two residents, one of whom desired exercise activities but was not engaged in any for 30 days, while the other had no activity care plan and did not participate in activities. The Activities Director acknowledged the lack of exercise programming and the absence of an activity preference sheet for the residents.
The facility failed to manage medication and bowel care for two residents. One resident did not receive the correct Lisinopril dosage due to a delay in updating the chart, while another resident experienced a delay in receiving bowel care, despite a protocol for administering milk of magnesia for constipation. Staff confirmed these lapses, highlighting unmet needs in care delivery.
The facility failed to implement pressure ulcer treatments and care plans for two residents, leading to deficiencies in care. One resident developed new skin irregularities and an unstageable pressure injury, with missing documentation of skin assessments. Another resident acquired a Stage 4 pressure ulcer due to a contracted arm, with no investigation conducted. These failures highlight inadequate pressure ulcer care and prevention.
A facility failed to provide appropriate dialysis care for a resident with end-stage kidney disease. The resident reported that staff did not check the dialysis access site for thrill and bruit after dialysis sessions. The care plan required monitoring for infection and bleeding and documenting weights, but the clinical record showed insufficient documentation. Staff acknowledged the lack of documentation regarding the dialysis access site and daily weights.
The facility failed to address pharmacy recommendations for two residents, leading to potential risks of adverse medication side effects. One resident with dementia was prescribed medications without proper physician documentation, and another resident with diabetes had unaddressed pharmacy recommendations for lab testing. Staff acknowledged communication breakdowns and lack of documentation.
A facility failed to monitor a resident's anticoagulant medication, Apixaban, for adverse side effects. The resident, admitted with a stroke and blood clot, had a physician order for Apixaban, but there was no documentation of monitoring in their electronic record. A staff member acknowledged this oversight.
The facility failed to monitor adverse side effects for residents on psychotropic medications, including a resident with dementia on haloperidol, another with narcissistic personality disorder on multiple psychotropics, and a third with depression on antidepressants. Staff acknowledged the lack of required daily monitoring documentation.
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.
Failure to Obtain Orders and Treat Non-Pressure Foot Ulcer After Admission
Penalty
Summary
The deficiency involves the facility’s failure to obtain physician orders and provide treatment for a non-pressure skin wound on a resident’s left foot following admission. The resident was admitted in 10/2025 with diagnoses including diabetes and a non-pressure chronic ulcer on the left foot, and hospital admission orders documented an ulcer of the left second toe with skin breakdown and toe pain. On the admission Nursing Database assessment the day after admission, nursing staff recorded scabs on the resident’s second and fourth toes and the top of the left foot, and an admission MDS completed the following week indicated a non-pressure chronic ulcer on the left foot. Despite these documented findings, there were no physician orders or wound treatments in the clinical record for the left foot ulcer from admission through mid-November. A nursing note later documented that staff sent a message to the physician about the left second toe scab and that treatment was initiated at that time. In interviews, an agency LPN who completed the admission assessment could not recall whether she confirmed physician orders for the wound and stated that normal practice would be to contact the physician if there were no orders, and a regional nurse stated that staff should ensure physician orders exist for residents with skin wounds. This failure to obtain and implement physician-directed wound care for the resident’s documented non-pressure ulcer and toe scabs during the identified period constituted the cited deficiency.
Lack of Staff and Resident Involvement in Facility Assessment
Penalty
Summary
The facility failed to demonstrate active involvement of staff and residents in determining staffing needs during its facility-wide assessment. The assessment identified insufficiencies in staffing, training, services, and personnel. Interviews revealed that CNAs and Resident Care Managers were not asked to provide input regarding staffing needs based on resident acuity, and there was no formal process for staff to give feedback to management about staffing. Members of the Resident Council reported that concerns about staffing had been discussed in meetings without resolution, and noted that agency staff required additional training. Documentation was not available to show how staffing hours or feedback from residents and staff were incorporated into the facility assessment.
Failure to Follow Infection Control Practices During COVID-19 Outbreak
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices during a COVID-19 outbreak affecting two halls. Used COVID-19 rapid tests were observed left on a bedside table near a facility exit and on top of the North Nurses Station, accessible to staff and residents passing by. Staff interviews confirmed that testing was supposed to occur in locked medication rooms, with used tests to be discarded immediately by a nurse, but this protocol was not followed. The Infection Preventionist acknowledged that the tests should not have been left in open areas and that the night nurse had left them out for an extended period. Additionally, signage for droplet precautions was found to be incorrect, with staff unable to see all necessary instructions, and the Infection Preventionist confirmed the signage did not meet expectations. Further observations revealed lapses in personal protective equipment (PPE) use and hand hygiene. A CNA was seen entering and exiting a room on droplet precautions without wearing a required face shield and failed to remove her N95 respirator before leaving the room. Another CNA was observed disposing of a used respirator and donning a new one without performing hand hygiene. The Infection Preventionist and other facility leaders stated that staff were expected to follow posted PPE guidelines and perform hand hygiene before donning clean masks, but these practices were not consistently followed. One resident involved had chronic obstructive pulmonary disease and was on special droplet precautions for COVID-19 at the time of the observed deficiencies.
Failure to Review Resident Rights During Resident Council Meetings
Penalty
Summary
The facility failed to ensure that residents were informed of their rights both orally and in writing on an ongoing basis. A review of Resident Council meeting minutes from three separate dates showed that resident rights were not reviewed during any of the meetings. During interviews, the Activity Director confirmed that resident rights were not discussed at Resident Council meetings, and members of the Resident Council also stated that these rights were not reviewed. The Administrator acknowledged that the expectation was for resident rights to be reviewed with residents during these meetings, but this did not occur.
Failure to Provide Bed-Hold Notification and Ombudsman Notification During Transfers and Discharges
Penalty
Summary
The facility failed to provide required written bed-hold notifications and did not notify the LTC Ombudsman during resident transfers to hospitals and discharges home. Specifically, for four residents with various diagnoses including heart failure, kidney disease, weakness, stroke, and alcohol abuse, there was no evidence in the clinical records that written notice of the facility's bed-hold policy was given to the residents or their representatives at the time of transfer or hospitalization. Additionally, there was no documentation that the LTC Ombudsman was notified of these transfers or discharges, as required by facility policy. Interviews with facility staff, including the Administrator and Social Services Director, confirmed that written bed-hold notifications were not provided and that the Ombudsman was not notified for the affected residents. The lack of documentation and staff acknowledgment of these omissions demonstrate that the facility did not follow its own policies regarding resident notification and communication with the Ombudsman during transfers and discharges.
Uncovered Exterior Refuse Containers Observed
Penalty
Summary
The facility failed to provide covered exterior refuse containers for three out of four observed locations. On multiple occasions, surveyors observed uncovered refuse containers outside various exits, each containing food debris and other trash. Staff, including the Maintenance Lead, confirmed that there were no lids available for these containers. Both the Administrator and the Regional Director of Quality Assurance acknowledged the presence of uncovered refuse containers at three exterior doors.
Failure to Complete Timely Comprehensive Assessment After Multiple Hospitalizations
Penalty
Summary
The facility failed to complete a comprehensive assessment for one resident who had a history of chronic kidney disease and multiple recent hospitalizations. Upon review, it was found that the resident's annual Minimum Data Set (MDS) assessment, which was due, remained incomplete beyond the required timeframe. Additionally, there was no evidence in the clinical record that a significant change assessment or an admissions assessment had been completed following the resident's multiple hospitalizations and subsequent return to the facility. Both the Regional Reimbursement Analyst and the Administrator acknowledged that the comprehensive assessment was not completed in a timely manner, despite the expectation for timely and accurate MDS assessments for each resident.
Failure to Coordinate Communication Services for Non-Verbal Resident
Penalty
Summary
The facility failed to coordinate appropriate services to address the communication needs of a resident with a persistent vegetative state and traumatic brain injury. Upon admission, the resident's ability to understand others was not assessed, and although a physician order was made for physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) at the family's request, there was no evidence that these referrals were promptly initiated. During a care conference, the family specifically requested referrals for OT, PT, SLP, and a neurologist, but staff were unclear about whether the SLP referral had been made. The resident's care plan was updated to reflect non-verbal communication needs, but staff interviews revealed uncertainty about how SLP could assist and a lack of timely follow-through on the requested services. Observations and interviews indicated that the resident attempted to communicate through non-verbal means such as eye movements, grunting, and swatting at staff. Staff members, including a CNA and the Activities Director, described the resident's responses to stimuli and attempts to make needs known, but there was no evidence of assessment for improved communication technology as requested by the family. The Regional Director of Quality Assurance confirmed that referrals for communication services were expected to be initiated as soon as requested, but acknowledged that there was a delay in providing these services for the resident.
Failure to Follow Physician Wound Care Orders Resulting in Infection
Penalty
Summary
The facility failed to follow physician orders for wound care for one resident who was admitted with a leg fracture. The orthopedic physician had ordered that the resident's dressing be removed one week after admission, the incision cleansed with warm water and soap, dried, covered with a nonadhesive pad or gauze, and the dressing changed every one to two days until a follow-up appointment. Staff were also instructed to monitor for signs of infection and contact Trauma/Orthopedics if any were observed. However, the physician's wound care order was not entered into the Treatment Administration Record (TAR), and there was no evidence that the wound care was completed as ordered. As a result, the resident's incision became red, swollen, and warm to the touch, with the resident reporting burning and tenderness. The resident stated that the dressing was not removed for nearly two weeks after admission and that staff did not check the incision until it became infected and painful, despite multiple reports of pain. Staff interviews confirmed that the physician's order was not placed on the TAR, dressing changes were not initiated, and the resident developed an incision infection. The process for entering and verifying new orders was reviewed, and it was acknowledged by multiple staff members that the order was missed.
Failure to Implement Smoking Safety Interventions
Penalty
Summary
The facility failed to implement care plan interventions related to smoking safety for a resident with a history of inhalant dependence and inhalant-induced dementia, who was assessed as cognitively intact. The resident's care plan required smoking only in designated areas, adherence to a smoking schedule, and storage of tobacco and fire materials in a lock box at the nurse's station. However, observations showed the resident repeatedly accessed smoking materials from the nurse's station counter, exited through the North exit door, and smoked or vaped outside of the designated smoking area, contrary to the care plan. Staff interviews confirmed that the resident was allowed to smoke independently, outside of scheduled times and designated areas, and that smoking materials were not consistently secured in the lock box as required. Additionally, staff were unclear about the frequency of required checks for burns on the resident, and the resident was observed leaving smoking materials unattended on the nurse's station counter. The Director of Nursing Services acknowledged that the only designated smoking area was the courtyard and that staff were expected to secure smoking materials immediately, but this was not consistently done. These actions and inactions resulted in the facility failing to ensure a safe environment free from accident hazards related to smoking, as outlined in the resident's care plan.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete annual performance reviews for two of five sampled CNA staff. Personnel records showed that one CNA, hired in May 2020, had their last performance review in June 2024, and another CNA, hired in August 2018, had their last performance review in August 2024. The administrator confirmed that annual staff evaluations were expected to be completed in a timely manner.
Failure to Timely Address and Document New Behavioral Changes
Penalty
Summary
The facility failed to timely address a newly identified behavior in a resident with a history of anxiety and heart failure. The resident, who was cognitively intact and had documented episodes of depression, exhibited inappropriate behaviors such as refusal of care, confabulation, and verbal aggression on multiple days, as recorded in the behavior monitoring record. Despite these behaviors, interventions were largely ineffective, and there was no documentation of additional behaviors in the progress notes for over a month. Staff interviews revealed that the resident had recently displayed physical aggression by banging a walker against the wall, but this incident was not reported or documented by staff who witnessed it, as they assumed others were aware. Further interviews indicated that key staff, including the Social Services Director and the Director of Nursing Services, were unaware of the resident's physical aggression and expected such incidents to be documented to facilitate timely intervention. The Social Services Director acknowledged the need for a new behavioral assessment and consideration of additional behavioral services due to the change in the resident's behavior. The facility assessment also indicated insufficient behavioral health staffing, which may have contributed to the lack of timely response and documentation regarding the resident's behavioral changes.
Unsecured Treatment Carts with Medications and Supplies
Penalty
Summary
Surveyors observed that treatment carts containing medications and medical supplies, including insulin, needles, glucometers, IV supplies, syringes, anticoagulant, and antibiotic medications, were left unlocked and unattended in two separate hallways. On one occasion, a staff member noticed the unlocked cart and secured it, although she was not responsible for it. The charge nurse responsible for the cart stated she typically locked it but was unsure why it was left unlocked in this instance. In both cases, staff confirmed that the expectation was for treatment carts to be locked at all times when unattended. These observations were made during random checks, and in both instances, staff and residents were seen walking by the unsecured carts. The unlocked carts contained medications and supplies that should have been secured according to facility policy and professional standards. No specific residents were identified as being directly involved or affected at the time of the observations.
Failure to Follow Up on Dental Services for a Resident
Penalty
Summary
The facility failed to follow up on dental services for one resident who was admitted with chronic kidney disease. According to the facility's policies, social services are responsible for assisting with dental appointments, transportation, and documenting all dental services in the resident's medical record. The resident's care plan required staff to coordinate dental care and transportation as needed. A review of the clinical record showed no evidence of dental services being referred or provided for the resident over a three-month period. Documentation indicated that a dental referral was made when the provider was at the facility, but there was no follow-up or documentation of a scheduled dental appointment, and the Social Services Director was unable to account for any further action taken.
Failure to Provide Scheduled Bathing and Shower Care
Penalty
Summary
A resident with chronic obstructive pulmonary disease and metabolic encephalopathy, who was dependent on staff for bathing and required two-person assistance, did not consistently receive scheduled bathing or shower care. The resident's care plan and admission assessments indicated the need for staff assistance with bathing. Bath/Shower task logs showed that showers were only documented as provided on three occasions, while scheduled shower days on three other dates were left blank with no documentation of care provided or refusals. Progress notes did not indicate that the resident was offered additional opportunities for bathing when a shower was missed or refused. Staff interviews revealed that sometimes tasks were not documented due to staff being too busy, and a resident care manager confirmed that blank logs indicated the task was not completed, with at least one missed shower attributed to short staffing.
Failure to Provide Adequate Staffing Resulting in Missed Resident Care
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents on multiple occasions, as evidenced by direct care staff daily reports, resident and staff interviews, and documentation reviews. On several dates, the number of Certified Nursing Assistants (CNAs) scheduled for both day and evening shifts was below the minimum required by Oregon state staffing ratios for the facility's census. This resulted in residents not receiving scheduled showers, delays in being put to bed, and missed oral care. Staff and residents consistently reported that management did not assist on the floor during shortages, and CNAs often skipped breaks or stayed late to complete tasks. Specific residents with diagnoses such as dementia, stroke, and cancer, who required assistance with activities of daily living (ADLs) like bathing, did not receive scheduled showers on the days when staffing was insufficient. Documentation was either missing or inaccurately indicated that residents refused care when, in fact, staff did not have time to provide it. Multiple staff members, including CNAs, LPNs, and the social service director, confirmed that showers and other care tasks were missed due to inadequate staffing, and that efforts to obtain agency staff were unsuccessful. The administrator and other management staff acknowledged ongoing staffing issues, confirming that resident needs were not met on the identified dates due to being short-staffed. The facility continued to admit new residents despite not having enough CNAs to provide required care, and staff reported that shortages were a frequent and unresolved problem. Residents expressed dissatisfaction with missed care, and staff described having to prioritize basic needs over other required tasks when working short.
Failure to Timely Resolve Resident Grievance Regarding Missing Property
Penalty
Summary
The facility failed to respond in a timely manner to a resident's grievance regarding missing property. According to the facility's grievance policy, grievances are to be addressed within five days of receipt, and the concerned party is to be informed of the resolution. A cognitively intact resident with a diagnosis of diabetes reported missing money from their wallet, specifying the denominations and amount believed to be missing. Staff, with the resident's permission, inspected the wallet and confirmed the discrepancy in the amount present. During the investigation, staff determined that theft was ruled out due to inconsistent statements from the resident, and the resident was offered the option to secure their remaining money. Despite this, the resident was not informed in a timely manner about whether the missing money would be reimbursed. Staff communication regarding the resolution was lacking, as one staff member was unsure about reimbursement and another did not communicate findings to the resident, assuming reimbursement would occur. The administrator acknowledged that the grievance policy was not followed, as the resident was not notified of the resolution within the required timeframe.
Failure to Protect Resident's Personal Property from Theft
Penalty
Summary
A resident with a history of stroke and documented as cognitively intact reported that their cell phone went missing after being placed on their bedside table following a call to their spouse. The resident stated that no one entered the room except staff and, occasionally, their roommate's visitors. Staff interviews confirmed that the resident had possession of the phone the evening before it was reported missing, and the phone was not found during a facility-wide search. The resident's spouse was able to use a phone locator to determine that the phone was located several blocks away from the facility the following day. The incident was reported to the police, and the resident's spouse subsequently requested reimbursement for the lost phone and the purchase of a new one. The report documents that the facility failed to protect the resident from the wrongful use or theft of their personal belongings, specifically the cell phone, as required. This deficiency was identified through interviews, record reviews, and the facility's own investigation into the missing property.
Resident's Right to Dignity and Self-Determination Not Upheld During Care
Penalty
Summary
A deficiency occurred when a staff member failed to honor a resident's right to dignity and self-determination. The resident, who was moderately cognitively impaired and diagnosed with dementia, was admitted to the facility in July 2024. On the date of the incident, a CNA attempted to change the resident's soiled shirt despite the resident's explicit refusal and requests to be left alone. The CNA proceeded to remove the shirt, which led to the resident becoming upset, fighting, and using strong language. The CNA later reported the resident's distress to an LPN, who confirmed the resident was angry about being made to change the shirt. Other staff members recalled the incident, with one CNA remembering the resident crying and reporting the situation to a nurse, and another LPN noting the resident appeared in distress and was forced to do something against their wishes. The resident did not use the word "abuse" but repeated the details of the incident, and two days later, no longer remembered it. The administrator and director of nursing services confirmed the accuracy of the incident and acknowledged the failure to maintain resident rights.
Failure to Provide Physician-Ordered Diets
Penalty
Summary
The facility failed to provide physician-ordered diets as prescribed for three residents, leading to significant health risks. Resident 57, who had a history of pneumonitis due to inhalation of food and severe dysphagia, was given food that did not meet the required minced and moist texture. This resulted in a severe coughing episode, indicating a risk of choking or aspiration. Staff were aware of the diet texture error but did not correct it due to a busy kitchen environment. Resident 3, diagnosed with difficulty swallowing, experienced a choking incident after being served inadequately prepared food. Despite a care plan that required supervision during meals and an easy-to-chew diet, Resident 3 choked on a piece of pork, leading to an emergency department visit. Documentation revealed multiple instances where Resident 3 refused to eat in the dining room, and there was insufficient staff to supervise meals in the resident's room. Resident 39, who had a stroke and dysphagia, was observed coughing while eating a tortilla, which was not appropriate for their easy chew 7 diet texture. The Certified Dietary Manager confirmed that the resident should have received bread instead. These incidents highlight the facility's failure to adhere to prescribed diet textures, posing significant health risks to the residents involved.
Removal Plan
- Resident 57 was assessed for signs and symptoms of aspiration, her/his physician was notified, and the resident was placed on alert charting.
- Staff 4 was suspended and slated for 1:1 inservice training related to food textures, ensuring food textures served matched the meal ticket, and the process for what to do if there was a discrepancy.
- Kitchen staff currently working were trained regarding proper diet textures. Other kitchen staff were slated to be educated until 100% were inserviced. Inserving was scheduled to be provided by a Certified Dietary Manager independent of the facility.
- Nursing staff were slated to be inserviced regarding appropriate food textures and ensuring residents received the correct texture.
- All residents with mechanically altered diets would have their meal tickets audited for correct texture prior to leaving the kitchen by the Certified Dietary Manager or designee, and a second check would occur by IDT team members in collaboration with CNAs prior to meals being served to residents.
- Audits would be conducted of each meal. All findings were to be reported to the QAPI committee. Audits were to be conducted by the Certified Dietary Manager or designee.
Deficiency in Meal Temperature and Flavor
Penalty
Summary
The facility failed to ensure that meals were served at appropriate temperatures and with proper flavor, affecting the palatability and safety of the food. On July 18, 2024, during a lunch service, sample plates were observed to contain cold and underdone au gratin potatoes, cold and firm broccoli, melted ice cream, and warm milk served at 64 degrees. The Certified Dietary Manager acknowledged these issues, confirming that the meal temperatures, flavors, and palatability were not appropriate. Additionally, a resident with diagnoses including malnutrition and diabetes reported consistent issues with the food quality. The resident stated that the food was bland, over-ripe, dry, tough, and always cold. Observations on July 18, 2024, during breakfast and lunch confirmed the resident's complaints, with meals appearing unappetizing and lacking flavor. A staff member, an RCM-LPN, also observed the resident's lunch and agreed that it did not appear appetizing or appealing.
Failure to Follow Menu Recipes
Penalty
Summary
The facility failed to adhere to established recipes to meet menu and therapeutic standards, as observed in the kitchen. On the specified date, the posted lunch menu included breaded pork cutlet, au gratin potatoes, and cauliflower, with an alternative menu of sloppy joes, cheddar mash potatoes, and broccoli. However, the cook, who had been employed for three weeks, reported that no recipes were provided during his training, and none were followed in preparing the lunch meal. The Certified Dietary Manager confirmed that a new menu system with recipes was introduced in June 2024, and recipes should have been printed and followed for all therapeutic diets. This failure placed residents at risk for lack of meal satisfaction and compromised nutrition.
Failure to Monitor Dishwasher Chemical Concentration
Penalty
Summary
The facility failed to ensure proper sanitation processes in the kitchen, specifically regarding the monitoring of chemical concentration levels in the low-temperature dishwasher. From July 1 to July 14, 2024, there was no documentation of chemical concentration levels, which are crucial for ensuring dishes are properly sanitized. On July 15, 2024, a Dietary Aide was observed using the dishwasher without monitoring the chemical concentration, as she had not been instructed to do so. The Dietary Services Manager acknowledged the oversight and admitted reliance on monthly inspections by the chemical supplier instead of daily monitoring. Additionally, the Certified Dietary Manager confirmed that the form used for monitoring the dishwasher was inadequate, as it did not include a section for documenting chemical sanitizer concentration, which should be logged daily.
Insufficient Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of residents, as evidenced by multiple observations and interviews. Residents and staff reported long wait times for call lights to be answered, with some residents waiting up to 45 minutes for assistance with toileting and other needs. This issue was prevalent across different shifts, particularly during the night shift, and was corroborated by council meeting minutes and staff interviews. Residents expressed dissatisfaction with the delays, and staff acknowledged being overworked and unable to complete their tasks due to understaffing. Specific incidents highlighted the impact of insufficient staffing on resident care. For instance, a resident with a fractured pelvis and bladder incontinence waited 45 minutes for toileting assistance during dinner time, leading to episodes of incontinence. The resident's care plan required substantial assistance with transfers, but the staffing shortages hindered timely care. Staff confirmed the complaint and noted that call wait times often exceeded the facility's expectation of 15 to 20 minutes. Staff interviews revealed that the facility frequently experienced CNA shortages, with staff calling off work shortly before shifts. This led to incomplete care tasks, such as showers and incontinent care, resulting in skin issues for residents. Staff reported burnout and high turnover due to the ongoing understaffing, which further exacerbated the problem. The facility's administration acknowledged the staffing issues, confirming the challenges in meeting residents' needs effectively.
Failure to Maintain Consistent RN Coverage
Penalty
Summary
The facility failed to staff a registered nurse (RN) for eight consecutive hours per day, seven days a week, for 34 out of 126 days reviewed. This deficiency was identified through a review of the Direct Care Staff Daily Report sheets covering several periods from January to July 2024. Specific dates were noted where RN coverage was lacking, including multiple days in January, February, March, June, and July. This lack of consistent RN coverage placed residents at risk for unmet assessment needs. During an interview on July 19, 2024, the facility's administrator, director of nursing services (DNS), regional support lead, and regional nurse consultant acknowledged the issue, noting that they believed RN coverage was better than documented and reported that two RNs had their employment terminated.
Failure to Post Accurate Staffing Information
Penalty
Summary
The facility failed to post accurate and complete staffing information, as observed on multiple occasions. On several dates, the Direct Care Staff Daily Report (DCSDR) was posted without documenting staff hours for Licensed Practical Nurses (LPNs) or Certified Nursing Assistants (CNAs). Witness 1, a staff member, revealed that nurses were instructed to fill in staff numbers without hours, with the expectation that administration would complete the form the following day. This practice was confirmed by multiple staff members, including the Administrator and Regional Support Lead, who acknowledged ongoing issues with staff not adding up the hours on the DCSDR.
Inadequate CNA Training Hours
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistant (CNA) staff received the required 12 hours of in-service training annually, as evidenced by a review of training records for five randomly selected staff members. Staff members hired between 2019 and 2022 had significantly less documented training than required, with one staff member having only 15 minutes of training over a year. During an interview, the facility's administrator, Director of Nursing Services (DNS), Regional Support Lead, and Regional Nurse Consultant acknowledged that staff were not obtaining sign-up sheets for trainings, which hindered the tracking of training hours. This deficiency placed residents at risk due to the lack of competent staff.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean and homelike environment for several residents, as observed during a survey. Multiple residents, including those with reduced mobility, end-of-life care, heart disease, stroke, and anxiety disorder, were found to be living in rooms with significant flooring damage. Observations included dents with black marks on the floors, gray substance lines, and aged, dingy flooring. In some cases, the flooring was chipped, missing pieces, or had been patched with putty. Additionally, there were issues with the cleanliness of the bathrooms, with gray and black substances observed around toilets and on the floors. The survey also noted environmental deficiencies in the facility's hallways, where large dark stains and black coloration were observed on the carpet. Ceiling damage was also noted in one resident's room, with leakage damage and dark brown dried debris on the wall. These conditions were confirmed by the Maintenance Lead, who acknowledged the need for repairs. The report highlights the facility's failure to maintain a clean and homelike environment, impacting the quality of life for the residents involved.
Pest Infestation and Delayed Response in Resident Areas
Penalty
Summary
The facility failed to maintain a pest-free environment, as evidenced by the presence of flies and maggots in resident areas. A work order was submitted on July 6, 2024, indicating an excessive amount of flies in the main area and resident rooms in the south part of the building. Despite this, the issue was not addressed until July 8, 2024, when the Maintenance Lead walked around the building but did not observe any issues. Pest control did not arrive until July 10, 2024. On July 13, 2024, a resident was found with maggots on their bed, which were traced back to their wound dressing, leading to their transport to the hospital. The resident had previously complained about flies landing on their food and foot, but no action was taken. The situation was further exacerbated when the resident returned from the hospital to find flies still present in their room. Staff were directed to deep clean the room, but the resident remained in the room during the process, necessitating a second cleaning. The facility administration was informed of the maggot issue early in the morning, but did not arrive until after noon. An investigation was conducted by the Director of Nursing Services and the Regional Nurse Consultant, who acknowledged the facility's lack of awareness regarding the initial work order related to flies. This oversight placed residents at risk for pest infestation, as flies were also observed in the dining room, where residents had to swat them away from their meals.
Failure to Protect Resident from Harassment
Penalty
Summary
The facility failed to protect a resident, who was cognitively intact and had a history of PTSD and anxiety, from harassment and intimidation by another resident. The issue began when the resident politely asked the other resident not to be disruptive in the dining room, which led to the other resident becoming angry and subsequently engaging in behavior that made the resident feel harassed and anxious. Despite the resident's complaints to management and staff observations of the intimidating behavior, the facility did not take effective action to prevent the harassment. Staff members reported that the resident felt scared, intimidated, and uncomfortable due to the other resident's behavior, which included staring and following the resident to their room. Although staff were instructed to redirect the harassing resident, this approach was ineffective and often resulted in the resident becoming angry. The facility's management was aware of the situation but failed to implement measures to protect the resident, leading to a deficiency in ensuring residents were free from abuse.
Failure to Investigate Allegations of Resident Harassment
Penalty
Summary
The facility failed to investigate allegations of abuse involving a resident with PTSD and anxiety disorder, who felt harassed and intimidated by another resident. The incident began when the resident asked the other resident not to be disruptive in the dining room, leading to ongoing harassment. Despite multiple observations and staff reports of the harassing behavior, management did not take adequate steps to protect the resident or investigate the allegations. Staff members reported that the harassing resident frequently visited the resident's hall and room, causing the resident to feel scared and anxious. Although staff were instructed to redirect the harassing resident, this approach was ineffective and further angered the resident. The facility's management was aware of the situation but failed to take appropriate action to ensure the resident's safety and well-being.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to revise care plan interventions for three residents, leading to unmet needs. Resident 10, admitted with a broken arm, was at risk for contracture to the left fingers. Despite instructions on the Treatment Administration Record (TAR) to soak and wash the hand and apply a hand brace, the care plan lacked documentation regarding the hand contracture. Staff confirmed that the hand contracture should have been included in the care plan. Resident 24, admitted with aphasia and stroke, had a care plan indicating deficits in ADL performance and nutritional issues but lacked documentation on whether supervision or assistance with eating was required. Staff acknowledged that supervision and cueing for eating assistance should have been specified. Resident 17, admitted with alcohol dependency and narcissistic personality disorder, had a behavior care plan but was not care planned for alcohol dependency or worsening behaviors with alcohol consumption. Staff confirmed that alcohol consumption worsened Resident 17's behaviors, yet the care plan did not address this issue. The lack of appropriate care plan revisions for these residents placed them at risk for unmet needs, as confirmed by facility staff.
Failure to Provide Timely Assistance with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for three residents, leading to unmet needs. Resident 16, who was cognitively intact and required assistance with toileting due to bladder incontinence, experienced a delay in receiving help. Despite activating the call light, the resident waited 45 minutes for assistance, resulting in an incontinent episode. Staff confirmed the delay and acknowledged that the expected response time for call lights was 15 to 20 minutes. Resident 24, who had deficits in ADL performance due to stroke and dementia, was dependent on staff for bathing. Documentation revealed that the resident missed several showers, leading to body odor. Staff admitted that time constraints prevented completion of all tasks, and showers were sometimes falsely documented as refused. Similarly, Resident 40, who required assistance for personal hygiene, received fewer showers than scheduled due to staffing shortages. Observations noted poor hygiene, and staff acknowledged the need for improved training to ensure compliance with bathing schedules.
Failure to Timely Replace Hearing Aids for a Resident
Penalty
Summary
The facility failed to replace hearing aids in a timely manner for a resident with dementia and depression, leading to a deficiency in addressing sensory needs. The resident was admitted in 2022 and was assessed to have adequate hearing with the use of hearing aids. A care plan revised in June 2024 indicated the resident was to wear hearing aids in both ears to address a mild hearing deficit. However, observations in July 2024 revealed the resident was not wearing hearing aids, and staff confirmed the aids had been broken for three to four months. The resident was on a list for repair, but no action had been taken. Staff members, including a CNA and an LPN, acknowledged the absence of hearing aids since the resident moved to a new hall in April 2024. The Social Service Director was unaware of the issue, mistakenly believing the resident chose not to wear the aids.
Failure to Prevent Accidents and Timely Response to Condition Changes
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards and did not respond to changes in condition in a timely manner. Resident 65, who was admitted with a leg fracture, experienced a fall resulting in a swollen, bruised, and painful right lower extremity. An x-ray confirmed a right ankle fracture, but there was a delay in notifying the on-call physician and sending the resident to the emergency room. Staff 42 acknowledged not calling the on-call physician and only sending a message through the hospital messaging system, which delayed the necessary care for Resident 65. Additionally, the facility did not adhere to the care plan for Resident 66, who required two staff members for mechanical lift transfers due to diagnoses including COPD, generalized muscle weakness, and a transient ischemic attack. An incident occurred when a CNA attempted to transfer Resident 66 alone, resulting in the resident falling out of the lift sling and hitting her head on the floor. The care plan was not followed, as the transfer was conducted by one staff member instead of two, leading to the resident being sent to the hospital. Staff 43 admitted to not following the care plan due to being rushed.
Inadequate Nephrostomy Tube Care
Penalty
Summary
The facility failed to provide adequate catheter care for a resident with a nephrostomy tube, which placed the resident at risk for urinary infections. The resident was admitted with chronic kidney disease and had a nephrostomy tube placed. There was a physician order to cover the nephrostomy tube site and change the bandage daily, but there were no orders for nephrostomy care from March to May. The care plan was revised in July to include monitoring for complications, but it lacked specific interventions related to the nephrostomy. The resident expressed concerns about the placement and staff knowledge regarding the nephrostomy bag, reporting incidents of the bag bursting or leaking due to improper handling. Staff interviews revealed confusion about responsibility for the nephrostomy bag care, unclear instructions on bag placement, and issues with supply availability. Staff acknowledged the need for a systematic method to maintain supplies, additional CNA training, and a detailed care plan for the nephrostomy bag care and placement.
Failure to Obtain Oxygen Orders for Residents with COPD
Penalty
Summary
The facility failed to obtain necessary orders for oxygen use for two residents with chronic obstructive pulmonary disease (COPD), leading to unmet respiratory needs. Resident 30, admitted in April 2022, had a care plan for oxygen use as needed but lacked a current order for oxygen use in their medical record. Staff confirmed that Resident 30 used oxygen almost daily when experiencing shortness of breath, yet no formal order was documented. Similarly, Resident 63, admitted in 2024, had a physician order for oxygen at three liters per minute (LPM) as needed. However, the medical record showed continuous oxygen use without documentation of adherence to the prescribed LPM or the frequency of oxygen tubing changes. Staff confirmed the continuous use of oxygen, acknowledging the absence of a formal order for such use and the lack of documentation regarding tubing changes.
Missed CNA Performance Review During Staffing Transition
Penalty
Summary
The facility failed to complete annual performance reviews for a Certified Nursing Assistant (CNA), identified as Staff 9, who was hired on March 23, 2021. The only performance review provided for this staff member was dated April 30, 2022. This oversight was identified during an interview conducted on July 19, 2024, with the facility's Administrator, Director of Nursing Services (DNS), Regional Support Lead, and Regional Nurse Consultant. They acknowledged that the missed review occurred during a staffing transition, which placed residents at risk due to the potential lack of competent staff.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to provide risk and benefit information related to the use of antipsychotic medications to residents or their responsible parties prior to administration. This deficiency was identified for one of the five sampled residents, who was admitted with a diagnosis including dementia. The resident, who had a BIMS score indicating moderate cognitive impairment, was prescribed Haloperidol for anxiety and agitation. The medication was administered starting on 5/9/24, but the consent form for the use of psychotropic medication therapy was not signed until 5/16/24. This indicates that the responsible party was not informed about the risks and benefits of the medication before it was administered. During an interview, facility staff confirmed that medication consent forms were expected to be signed before administration, highlighting a lapse in protocol adherence.
Failure to Conduct Scheduled Care Conference
Penalty
Summary
The facility failed to conduct a care conference for a resident with dementia, admitted in November 2021, as scheduled. On July 18, 2024, a family member, Witness 6, reported that a care conference was scheduled for May 27, 2024, but it did not occur, and no rescheduling was communicated. Staff 15, an LPN Assistant RCM, confirmed the scheduled conference and noted that Witness 6 had no concerns when she inquired about it on the scheduled date, but also confirmed that the resident was not present. Similarly, Staff 33, the Social Service Coordinator, confirmed the absence of the resident and the lack of concerns from Witness 6. On July 19, 2024, Staff 32, an LPN RCM, and Staff 31, an SSD, both stated that care conferences should include the resident, family, and the interdisciplinary team (IDT), which comprises nursing, social services, therapy, dietary, and activities. Staff 31 acknowledged that the care conference did not occur and mentioned efforts to reschedule it.
Failure to Include Resident in Shower Schedule Decisions
Penalty
Summary
The facility failed to include a resident in decisions regarding their shower schedule, which is a violation of the resident's right to self-determination and choice. The resident, who was admitted in 2024 with diagnoses including diabetes and a foot ulcer, required assistance with transfers and dressing. A revised care plan indicated these needs. The resident's shower schedule was changed automatically following a room move, without prior discussion or consent from the resident. This change conflicted with the resident's weekly medical appointments, causing inconvenience. Staff acknowledged that the shower schedule should have been discussed with the resident before any changes were made.
Failure to Notify Provider of Resident's Refusals for Health Checks
Penalty
Summary
The facility failed to notify the provider of a resident's refusals for critical health checks, specifically capillary blood glucose (CBG) checks and orthostatic blood pressure measurements. The resident, admitted in September 2019 with a diagnosis of diabetes, had physician orders for weekly CBG checks and monthly orthostatic blood pressure assessments. However, the resident refused CBG checks on multiple occasions in May, June, and July 2024, and also refused orthostatic blood pressure checks in May and June 2024. Despite these refusals, there was no evidence in the medical record that the provider was informed of these refusals, as confirmed by a regional nurse consultant on July 19, 2024.
Failure to Provide Meaningful Activities for Residents
Penalty
Summary
The facility failed to assess and provide meaningful activities for two residents, leading to a lack of social interaction. Resident 36, who was cognitively intact and expressed a desire for group activities, particularly exercise, was not engaged in any activities for 30 days. Despite being aware of Resident 36's interest in exercise, the Activities Director acknowledged that current activities did not include exercise programming. Resident 42, diagnosed with an anxiety disorder, had no activity care plan, and did not participate in any activities for 30 days. The Activities Director admitted that an activity preference sheet was not completed for Resident 42.
Medication and Bowel Care Deficiencies
Penalty
Summary
The facility failed to implement proper medication management and bowel care for two residents, leading to unmet needs. Resident 17, who was admitted with a diagnosis of diabetes, had a physician's order to increase their Lisinopril dosage from 5 mg to 7.5 mg on 5/7/24. However, this change was not entered into the resident's chart until 6/15/24. During this period, the pharmacy sent the correct dosage, but staff continued to administer the incorrect 5 mg dose as per the outdated chart. Staff members, including an LPN and CMA, confirmed the discrepancy, and the DNS acknowledged the failure to update the chart promptly, leaving uncertainty about the duration the resident received the incorrect dosage. Resident 33, admitted with arthritis, experienced a lapse in bowel care. From 6/7/24 to 6/13/24, the resident did not have a bowel movement, and although the MAR indicated that milk of magnesia should be administered every 24 hours as needed for constipation, the resident only received the medication on 6/12/24, five days after the last recorded bowel movement. The facility's administrator, DNS, regional support lead, and regional nurse consultant confirmed that bowel care should have been provided sooner, indicating a failure to adhere to the prescribed bowel management protocol.
Failure to Implement Pressure Ulcer Care Plans
Penalty
Summary
The facility failed to implement appropriate pressure ulcer treatments and care plans for two residents, leading to deficiencies in care. Resident 3, admitted with a diagnosis of stroke, developed new skin irregularities with significant redness in the peri and sacral areas, as noted in a weekly skin audit. However, there was no documentation that the physician was informed of these changes. The Treatment Administration Record (TAR) indicated that bi-weekly skin checks were to be conducted, but there were inconsistencies in the documentation, with missing assessments for several dates. An external physician visit later identified an unstageable pressure injury on Resident 3's buttocks, and the physician requested an off-loading mattress and a facility skin assessment, which was not documented in the clinical records. Resident 1, admitted with an anoxic brain injury, developed an in-house acquired Stage 4 pressure ulcer on the left upper abdomen. Despite the severity of the ulcer, there was no investigation conducted to determine its cause. Staff interviews revealed that the ulcer was caused by the resident's contracted left arm pressing against the abdomen, but no further action was taken to investigate or address the issue. This lack of investigation and documentation highlights the facility's failure to provide adequate pressure ulcer care and prevention.
Failure to Provide Proper Dialysis Care
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident with end-stage kidney disease, who was admitted in 2024. The resident, who underwent dialysis three times a week, reported that upon returning from dialysis, staff did not check the access site for thrill and bruit, which are essential to ensure good blood flow in a dialysis fistula. The care plan dated 2/7/24 required staff to monitor the access site for infection and bleeding and to document weights. However, the resident's clinical record showed only six weights documented from 2/7/24 through 6/29/24, with no evidence of access site monitoring. Staff acknowledged the absence of documentation regarding the type of dialysis access site and the necessary care needs for the resident, as well as the lack of daily weight documentation.
Failure to Address Pharmacy Recommendations for Two Residents
Penalty
Summary
The facility failed to address pharmacy recommendations for two residents, leading to potential risks of adverse medication side effects. Resident 10, who was admitted with a diagnosis of dementia, was prescribed trazodone and promethazine for agitation, both limited to 14 days. However, the notes to the attending physician lacked the physician's signature, date, or clinical justification for extended use. The Medication Administration Record (MAR) indicated that trazodone was administered every 12 hours as needed for agitation, and promethazine every four hours as needed for agitation, nausea, and vomiting. A communication breakdown between the provider and the facility was acknowledged by the staff during an interview. Resident 17, admitted with a diagnosis of diabetes, had pharmacy recommendations for laboratory testing in May 2024. However, a review of the resident's medical record revealed that the last lab tests were completed in April 2023, and there was no documentation related to the May 2024 pharmacy recommendations. Staff confirmed that the resident often refused lab testing due to a fear of needles, and there was no documentation regarding the pharmacy recommendation for lab testing.
Failure to Monitor Anticoagulant Medication
Penalty
Summary
The facility failed to monitor the anticoagulant medication, Apixaban, for adverse side effects in one of the five sampled residents. This resident was admitted in 2023 with diagnoses including stroke and blood clot. A physician order dated 3/28/24 indicated that the resident was to receive Apixaban. However, there was no documentation in the resident's electronic record regarding the monitoring for adverse side effects of this medication. On 7/18/24, a staff member, identified as Staff 28 (RCM-LPN), acknowledged the absence of monitoring for adverse side effects in the resident's electronic record.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to consistently monitor residents on psychotropic medications, leading to the risk of residents receiving unnecessary medications. Resident 10, admitted with dementia, was administered haloperidol daily without daily documentation of monitoring for antipsychotic side effects. During an interview, facility staff acknowledged the expectation for daily monitoring, which was not met. Resident 17, with a diagnosis of narcissistic personality disorder, was prescribed four psychotropic medications, including olanzapine, diazepam, duloxetine, and trazodone. Despite a care plan in place since 2021 to monitor for adverse side effects, there was no evidence of such monitoring in the resident's medical record. Staff confirmed the lack of documentation. Similarly, Resident 27, diagnosed with depression, was prescribed Zoloft and Remeron, but there was no monitoring for adverse side effects documented in the electronic record, as confirmed by staff.
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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