Avamere Rehabilitation Of Newport
Inspection history, citations, penalties and survey trends for this long-term care facility in Newport, Oregon.
- Location
- 835 Sw 11th Street, Newport, Oregon 97365
- CMS Provider Number
- 385162
- Inspections on file
- 13
- Latest survey
- August 8, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Avamere Rehabilitation Of Newport during CMS and state inspections, most recent first.
Inadequate staffing and poor coordination between dietary and nursing staff led to routine delays in meal service, with meal carts arriving up to 74 minutes late and impacting timely diabetic medication administration. Staff reported insufficient communication about delays and a lack of clear expectations for meal service timing.
Surveyors identified unsanitary conditions in the kitchen, including a cabinet door with exposed wood and removable paint, a detached baseboard with inaccessible debris, and an ice machine installed without a required air gap and surrounded by black debris. The Dietary Manager and Corporate Maintenance acknowledged these issues and improper installation practices.
A facility did not ensure that a resident was fully informed about the binding arbitration agreement at admission. The Medical Records Director incorrectly explained that the resident could still go to court if their rights were violated, which contradicted the actual terms of the agreement. The Administrator confirmed that the information provided to the resident was not accurate.
A resident with a history of stroke and aphasia, but cognitively intact, had important preferences for bathing and bedtime that were not documented in the care plan. Staff interviews revealed inconsistent awareness of these preferences, resulting in the resident being awakened earlier than desired and causing distress. The lack of clear documentation and communication led to the resident's choices not being consistently honored.
A resident with a history of stroke and hypertension had their Metoprolol held multiple times due to low blood pressure, but the physician was not notified as required by orders. Review of records and staff interviews confirmed the lack of provider notification and documentation, despite facility expectations for communication in such cases.
A resident with hemiplegia and a history of stroke was found to have long, jagged, and dirty fingernails and toenails, despite being dependent on staff for ADLs. Staff indicated that nail care was provided on shower days and as needed, but the resident's nails had not been trimmed for at least two weeks, resulting in unaddressed hygiene needs.
A resident with a history of stroke and aphasia, identified as at risk for skin impairment, developed a 5 cm dark lesion on the scalp. Despite care plan instructions and the resident expressing concern, staff did not monitor or document changes to the lesion, and no follow-up was recorded. Staff interviews confirmed awareness of the lesion but a lack of monitoring and documentation.
A resident with depression and recent suicidal ideations was not provided with an updated behavioral health care plan or safety interventions following a hospital evaluation. CNAs were unaware of the resident's mental health status due to lack of information in the Kardex and shift reports, and a required follow-up call to Mental Health was not completed.
A resident with diabetes and diabetic neuropathy was admitted with orders for daily insulin and fasting serum blood sugar (FSBS) monitoring, but FSBS results were not documented for two months. The resident reported infrequent monitoring, and staff confirmed the FSBS order was missed during admission. Staff also stated that FSBS are usually obtained weekly and that nurse managers are expected to review new orders within 24 hours.
The facility failed to ensure hair and beard restraints were worn during meal preparation. Staff were observed preparing food without the required restraints, contrary to the facility's policy. The Dietary Manager acknowledged the requirement for staff to wear these restraints.
The facility failed to ensure a system was in place to offer COVID-19 vaccines to staff. A CNA was not offered the COVID-19 vaccine, nor was there documentation of education related to the vaccine. The Resident Care Manager confirmed that she stopped offering the COVID-19 vaccine to staff in August 2023.
The facility failed to offer pneumonia vaccines to eligible residents, including those with heart disease, lung disease, diabetes, and stroke. Despite being eligible, these residents were not offered additional doses, as acknowledged by the Resident Care Manager.
The facility failed to ensure a resident was shaved, compromising the resident's hygiene. Despite being cognitively intact and expressing a preference for no facial hair, the resident was observed with facial hair on multiple occasions. Staff confirmed the resident should have been shaved but was not, and the Resident Care Manager and DNS acknowledged that staff were expected to shave the resident as soon as possible if missed on a shower day.
A resident with hearing loss was observed wearing only one hearing aid due to the other being broken. Despite informing staff, no appointment was made to fix the broken hearing aid. Staff confirmed the resident should have been wearing two hearing aids and acknowledged the oversight.
A resident with a genetic muscular disease and a contracture of the left hand was observed without the required brace on multiple occasions. The washable part of the brace was taken to the laundry and not returned, making it unavailable. The Resident Care Manager was unaware of the issue and confirmed the resident only had one brace that needed daily application.
The facility failed to follow the care plan for a fall-risk resident with a history of stroke, leaving them unattended in their room in a wheelchair on multiple occasions. Staff were unaware of the care plan requirements, and the Resident Care Manager confirmed the oversight.
Delayed Meal Service Due to Inadequate Staffing and Poor Coordination
Penalty
Summary
The facility failed to provide adequate staffing and coordination for meal service in the kitchen, resulting in significant delays in meal delivery to residents. Scheduled lunch service was to begin at 11:30 AM, but observations showed that meal carts arrived late to dining areas, with the final cart arriving up to 74 minutes after the scheduled start time. Staff interviews confirmed that such delays occurred routinely one to two times per week, with delays lasting up to 45 minutes. Staff responsible for meal preparation and delivery reported being unable to complete tasks on time due to limited personnel and space constraints in the kitchen. Communication between dietary and nursing staff was insufficient, as nursing staff were rarely notified of late meals, impacting the administration of diabetic medications that needed to be given prior to meals. The lack of clearly defined expectations for meal service timing between departments contributed to the ongoing delays. The facility administrator acknowledged the absence of established protocols for meal service timing and emphasized the need for improved teamwork, communication, and kitchen efficiency.
Sanitation and Plumbing Deficiencies in Kitchen Environment
Penalty
Summary
Surveyors observed multiple sanitation and maintenance deficiencies in the facility kitchen. A white painted cabinet door under the sink in the food preparation area had exposed wood and black marks around the edge, with paint that was easily removed when rubbed. The baseboard under a counter was detached from the cabinet, and black debris was visible between the baseboard and the cabinet in an area not accessible for cleaning. The ice machine was directly plumbed from the outside without a required one-inch air gap, and a metal plate attached to the floor beneath the ice machine had a one-inch-wide rim of black debris around it. The Dietary Manager acknowledged the presence of uncleanable surfaces and improper installation of the ice machine, and Corporate Maintenance confirmed the expectation for a one-inch air gap for correct installation.
Failure to Properly Inform Residents of Binding Arbitration Agreement
Penalty
Summary
The facility failed to ensure that residents were fully informed and understood the binding arbitration agreement, as required. The facility's Patient and Facility Arbitration Agreement stated that by signing, parties waive their constitutional right to have claims decided in court before a judge and jury. Interviews revealed that all residents had signed the agreement, and the Medical Records Director was responsible for explaining it upon admission. However, the explanation provided to residents was incorrect, as it included information that residents could still go to court if their rights were violated, which contradicts the terms of the binding arbitration agreement. The Administrator acknowledged that the facility was not providing correct information regarding the agreement.
Failure to Communicate and Honor Resident Preferences for Daily Routines
Penalty
Summary
A deficiency was identified when the facility failed to ensure that a resident's preferences regarding bathing and bedtime routines were communicated and honored. The resident, who had a history of stroke and aphasia but was assessed as cognitively intact, placed high importance on their bathing and bedtime preferences. Despite this, the care plan did not document these preferences, and staff interviews revealed inconsistent awareness and understanding of the resident's desired routines. One CNA reported that some staff were unaware of the resident's preference to sleep in, leading to the resident being awakened earlier than desired, which caused distress. Another CNA noted difficulty in understanding the resident's preferences due to the lack of detailed information in the care plan. Further interviews indicated that while the Activities Director had interviewed the resident about preferences, updates were only made to the care plan for recreational activities, not for daily routines such as bathing or bedtime. The Interim DNS/RNCM acknowledged insufficient oversight in ensuring the resident's preferences were addressed and expected a person-centered care plan to be in place. The lack of clear documentation and communication of the resident's preferences placed the resident at risk for not having their choices honored.
Failure to Notify Physician After Holding Antihypertensive Medication
Penalty
Summary
The facility failed to notify the physician after holding blood pressure medication for a resident with a history of stroke and hypertension. Physician orders specified that Metoprolol Tartrate should be held if the resident's blood pressure was less than 100/55, and the physician should be notified for further instructions. Medication administration records showed multiple instances where Metoprolol was held due to low blood pressure readings, but there was no documentation that the physician was notified as required. Interviews with staff revealed that the expected process was to inform the charge nurse and document the event in the provider's communication book. However, review of the communication book showed no entries regarding the held medication for this resident. The interim DNS and the physician assistant both confirmed there was no evidence of provider notification, and the physician assistant stated he would have adjusted the medication dosage if he had been informed of the low blood pressures.
Failure to Provide Timely Nail Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with a history of cerebral infarction and left-sided hemiplegia, who was dependent on staff for activities of daily living, was observed to have long, jagged, and dirty fingernails and toenails. The resident reported that their fingernails needed to be trimmed. Staff interviews revealed that nail care was typically provided on shower days, and a CNA stated that nail care for this resident had last been performed two weeks prior. Upon further observation with an LPN Resident Care Manager, the resident's nails remained in poor condition, and it was confirmed that CNA staff were expected to provide nail care during showers and as needed between showers.
Failure to Monitor and Document Resident's Skin Lesion
Penalty
Summary
Facility staff failed to monitor and document changes in a resident's skin condition as required by facility policy. The resident, who had a history of stroke and aphasia but was assessed as cognitively intact, was identified as being at risk for skin impairment. Despite a care plan instructing staff to report and monitor changes in skin condition, a 5 cm dark lesion was noted on the resident's scalp. The resident expressed concern about the lesion through nonverbal cues, but there was no documentation of ongoing monitoring or follow-up in the clinical record after the lesion was initially identified. Staff interviews confirmed that the registered nurse was aware of the scalp lesion but did not monitor it, and the resident care manager was unaware of any further physician follow-up. Weekly skin audits and the treatment administration record did not reflect the presence or monitoring of the lesion. This lack of monitoring and documentation resulted in a failure to provide appropriate treatment and care according to the resident's needs and preferences.
Failure to Update Behavioral Health Care Plan and Communicate Suicidal Ideation
Penalty
Summary
The facility failed to complete a baseline care plan and provide ongoing behavioral health services for a resident admitted with depression who experienced suicidal ideations. After being sent to the hospital for evaluation due to suicidal ideations, the resident returned to the facility, and documentation indicated the resident was not at risk for imminent harm. However, the resident declined to complete a safety plan but agreed to a follow-up call with Mental Health, which was not documented as completed. Interviews with CNAs revealed they were unaware of the resident's recent suicidal ideations, as this information was not included in the Kardex or communicated during shift reports. A review of the care plan and Kardex showed no evidence of a mental health or suicidal ideation care plan or safety interventions. The interim DNS/RNCM was also unaware of the relevant after-visit summary and mental health notes in the chart and confirmed that the care plan and Kardex were not updated and the follow-up call to Mental Health had not occurred.
Failure to Obtain Ordered Fasting Serum Blood Sugars for Diabetic Resident
Penalty
Summary
The facility failed to obtain fasting serum blood sugars (FSBS) as ordered for one resident with diabetes and diabetic neuropathy. Upon admission, the resident had hospital discharge orders for daily insulin injections and FSBS monitoring. A revised care plan also indicated the need for FSBS to be completed as ordered. However, diabetic administration records for two consecutive months showed no documented FSBS results for this resident. The resident reported that FSBS were rarely monitored, and staff interviews confirmed that the hospital discharge order for FSBS was missed during the admission process. Staff also indicated that FSBS were typically obtained weekly for diabetic residents, and nurse managers were expected to review new resident orders within 24 hours to ensure accuracy.
Failure to Use Hair and Beard Restraints During Meal Preparation
Penalty
Summary
The facility failed to ensure hair and beard restraints were worn during meal preparation, as observed on 4/3/24. Staff 13 (Dietary Manager), Staff 14 (Cook), and Staff 15 (Cook) were seen preparing food in the kitchen without hair and beard restraints. Staff 13 indicated that staff were told they were not required to wear hair restraints unless their hair was long and were also told they were not required to wear beard restraints. This was contrary to the facility's policy on Food Handling, revised in 1/2018, which required food and nutrition services staff to wear hair and beard restraints. Staff 13 acknowledged that staff were supposed to wear these restraints while working in the kitchen.
Failure to Offer COVID-19 Vaccine to Staff
Penalty
Summary
The facility failed to ensure a system was in place to offer COVID-19 vaccines to staff. Specifically, it was found that a CNA was not offered the COVID-19 vaccine, nor was there documentation of education related to the vaccine. This was confirmed during an interview with the Resident Care Manager, who stated that she stopped offering the COVID-19 vaccine to staff in August 2023.
Failure to Offer Pneumonia Vaccines to Eligible Residents
Penalty
Summary
The facility failed to ensure residents were offered a pneumonia vaccine, placing them at risk for infections. Resident 1, admitted in 2023 with heart disease, received a pneumonia vaccine in 2015 but was not offered another vaccine despite being eligible. Similarly, Resident 9, admitted in 2017 with lung disease, received a pneumonia vaccine in 2016 but was not offered another dose despite eligibility. Staff 6, the Resident Care Manager, acknowledged these oversights on 4/3/24 at 9:19 AM. Resident 11, admitted in 2018 with diabetes, refused a pneumonia vaccine in 2018 but was not offered additional vaccines thereafter. Resident 13, admitted in 2018 with a stroke, received a pneumonia vaccine in 2013 but was not offered another vaccine despite being eligible. Staff 6 also acknowledged these deficiencies. The failure to offer pneumonia vaccines to these residents was identified through interviews and record reviews.
Failure to Assist Resident with Shaving
Penalty
Summary
The facility failed to ensure a resident was shaved, which compromised the resident's hygiene. Resident 4, who was admitted in 2023 with a diagnosis of a stroke and was cognitively intact, expressed a preference for no facial hair and required staff assistance to shave on shower days. On multiple occasions, Resident 4 was observed with facial hair despite being assisted with showers. Staff 4 confirmed that the resident should have been shaved but was not. The Resident Care Manager and DNS acknowledged that if a resident was not shaved on their shower day, staff were expected to shave the resident as soon as possible and not wait for the next scheduled shower day.
Failure to Assist Resident with Hearing Aid Device
Penalty
Summary
The facility failed to assist a resident with a hearing aid device, leading to a deficiency. Resident 30, who was admitted in 2023 with a diagnosis of hearing loss, was observed on multiple occasions to have difficulty hearing staff and her/his roommate. The resident was wearing only one hearing aid, and upon interview, stated that the other hearing aid was broken and that staff had been informed but no appointment was made to fix it. Staff members confirmed that the resident was supposed to wear two hearing aids and acknowledged that the broken hearing aid should have been reported to the Resident Care Manager or Social Services for repair.
Failure to Apply Brace for Resident with Contracture
Penalty
Summary
The facility failed to apply a brace for a resident with a genetic muscular disease, leading to a deficiency in maintaining or improving the resident's range of motion (ROM). The resident, who had a contracture of the left hand, was observed without the required brace on multiple occasions. A CNA reported that the washable part of the brace was dirty and taken to the laundry, but it had not been returned, making the brace unavailable for use. The Resident Care Manager was unaware of the missing brace and confirmed that the resident only had one brace, which needed to be applied daily.
Failure to Follow Care Plan for Fall-Risk Resident
Penalty
Summary
The facility failed to provide care and services as care planned for a resident who was at risk for falls due to a stroke, incontinence, gait/balance problems, and left-sided paralysis. The resident's care plan indicated that they should not be left unattended in their room while in a wheelchair. However, the resident was observed unattended in their room in a wheelchair on multiple occasions. Interviews with CNAs revealed that they were not aware of the care plan requirement. The Resident Care Manager acknowledged that the resident was a fall risk and should not have been left unattended, confirming that staff were not following the care plan.
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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