Avamere Rehabilitation Of Oregon City
Inspection history, citations, penalties and survey trends for this long-term care facility in Oregon City, Oregon.
- Location
- 1400 Division Street, Oregon City, Oregon 97045
- CMS Provider Number
- 385125
- Inspections on file
- 22
- Latest survey
- August 29, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Avamere Rehabilitation Of Oregon City during CMS and state inspections, most recent first.
A resident with limited mobility and a neck fracture, who required two-person assistance for transfers, was injured when a CNA attempted to transfer the resident alone from the commode. This failure to follow the resident's care plan resulted in a fall and a fractured right arm, as confirmed by facility staff and medical records.
Surveyors observed that a CMA pre-prepared and stored multiple residents' medications in plastic cups labeled only with room numbers in a medication cart, including in the narcotic drawer, rather than storing them in their original packaging and locked compartments as required. The DON confirmed this was not proper medication storage.
A resident receiving duloxetine and Wellbutrin for depression was not informed of the risks and benefits of these psychotropic medications, as confirmed by the DON and a review of the medical record.
A resident with asthma and congestive heart failure was found to have a large section of missing sheet rock and debris behind their bed, resulting from the bed hitting the wall. The damage, which had been present for several months, was not repaired despite staff and maintenance being aware of the issue. The Administrator confirmed the repair was not completed in a timely manner.
A resident with a history of major depressive disorder and PTSD, who was cognitively intact, reported that staff mocked her delusions on multiple occasions. Although the resident shared these concerns with Social Services, no documentation or investigation occurred because the resident feared retaliation and did not want to file a grievance. The administrator was not informed of the allegations, resulting in a failure to investigate the reported mental abuse.
A resident with schizoaffective disorder, bipolar type, and probable developmental delay did not receive a required PASARR Level II assessment for serious mental illness and intellectual/developmental disability, despite recommendations and supporting documentation. Social services staff were unaware of the need to request the assessment, and the administrator confirmed it was not completed.
A resident with hearing impairment was left without properly fitting or working hearing aids, despite repeated reports to staff and documentation of the issue. Staff interviews revealed that the devices had not functioned since admission, and social services did not take steps to repair or replace them, resulting in the resident being unable to hear adequately.
A resident with limited mobility and a history of pleural effusion was not provided restorative services to maintain or improve range of motion after discharge from PT, despite expressing interest and being identified as a good candidate. Staff interviews revealed the resident was not enrolled in the restorative program due to a full caseload and lack of follow-up, resulting in the resident not receiving ROM exercises.
Staff did not consistently follow transmission-based precautions for a resident with C. diff, including entering the room without PPE, failing to perform hand hygiene after contact, and allowing the resident to ambulate in common areas despite isolation requirements. Staff interviews confirmed knowledge of the protocols, but adherence was lacking.
A facility failed to properly prepare a resident with depression, anxiety, alcohol abuse, and cannabis dependence for a facility-initiated discharge. The resident was given a list of assisted living facilities but lacked sufficient preparation and orientation. After being absent for over 24 hours, the resident was discharged AMA without medications. Staff confirmed the discharge was facility-initiated, and the Administrator was unaware that an AMA discharge required resident initiation.
A facility failed to follow physician's orders for a resident with diabetes, resulting in a deficiency in medication management. The resident had specific insulin orders requiring physician notification if blood glucose levels exceeded 351, but the facility did not notify the physician on nine occasions when levels were above this threshold. Staff acknowledged the oversight, which placed the resident at risk for complications.
The facility failed to provide palatable food to residents, risking unmet nutritional needs. Residents with various medical conditions reported dissatisfaction with the food quality, describing it as tough, spicy, and lacking flavor. Test trays confirmed these issues, with meals being unpalatable and not served at appetizing temperatures. Staff members also noted poor food quality, confirming residents' complaints.
Failure to Follow Care Plan Results in Resident Fall and Fracture
Penalty
Summary
A resident with a history of neck fracture and limited mobility was admitted to the facility and required a two-person assist for transfers during toileting, as documented in the care plan. Despite this, a CNA attempted to transfer the resident alone from the commode, resulting in the resident slipping and falling to the floor. The fall led to a fracture of the resident's right arm. The resident was cognitively intact at the time, with a BIMS score of 15 out of 15, and was aware of the care plan requirements for two-person assistance during transfers. Interviews and record reviews confirmed that the CNA did not follow the resident's individualized care plan, which specifically required two-person assistance for transfers and toileting. Facility staff, including the RCM and Administrator, acknowledged that the failure to adhere to the care plan directly led to the resident's fall and subsequent injury. The incident was substantiated by the facility's investigation and the resident's hospital discharge summary, which documented the right arm fracture resulting from the fall.
Improper Storage and Pre-Preparation of Medications in Medication Cart
Penalty
Summary
Surveyors found that the facility failed to ensure proper storage of biologicals and medications in accordance with its own policies and accepted professional standards. During observation, six plastic medication cups containing medications and labeled only with resident room numbers were found in the top drawer of a medication cart, and an additional unlabeled medication cup with pills was found in the narcotic locked box of the same cart. These medications were pre-prepared for administration to multiple residents, including those receiving medications such as atorvastatin, gabapentin, sertraline, simvastatin, docusate, topiramate, dicyclomine, prazosin, senokot, trazodone, buspirone, Tylenol, calcium supplements, icosapent, baclofen, Prilosec, hydroxyzine, risperdal, sucralfate, morphine, dilaudid, aripiprazole, mirtazapine, and tamsulosin. A certified medication aide (CMA) acknowledged that she routinely prepped scheduled medications early and left them in the medication cart, labeling the cups with room numbers and placing them in the top shelf or narcotic drawer. She stated this was her usual process due to challenges in administering medications in a timely manner, and admitted it was not best practice. The Director of Nursing confirmed the presence of pre-prepped medications in the cart and acknowledged that this was not proper medication storage.
Failure to Inform Resident of Psychotropic Medication Risks and Benefits
Penalty
Summary
A resident admitted with a diagnosis of depression was prescribed duloxetine and Wellbutrin, both antidepressant medications, as indicated in the physician orders and medication administration record. Despite receiving these medications daily, there was no documentation in the medical record that the resident had been informed in advance about the risks and benefits associated with either medication. During an interview, the Director of Nursing confirmed that the resident had not been provided with this information.
Failure to Maintain a Homelike and Safe Resident Environment
Penalty
Summary
The facility failed to provide a homelike environment for one resident who had been admitted with asthma and congestive heart failure. The resident's care plan included interventions to minimize exposure to asthma triggers. However, a large section of sheet rock was missing from the wall behind the resident's bed, with debris and dust scattered on the baseboard and floor. The resident reported that the damage was caused by the bed hitting the wall and that it had not been repaired. Staff interviews confirmed that the wall had been in disrepair for at least five and a half to eight months. The Maintenance Director acknowledged awareness of the issue but stated repairs had not been completed due to other projects. The Administrator also acknowledged the wall was not repaired in a timely manner.
Failure to Investigate Allegations of Mental Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of mental abuse for a resident with major depressive disorder and post-traumatic stress disorder, who was cognitively intact. The resident reported that staff had mocked and made fun of her delusions on several occasions, and stated that she had reported these incidents to someone in April, but no action was taken. The resident expressed that the mocking had a negative mental impact and made her reluctant to report further delusions. Social Services staff confirmed that the resident reported staff making fun of her, but because the resident did not want to file a grievance due to fear of retaliation, no progress note was made and the concerns were not escalated to facility administration for investigation. The administrator was unaware of the allegations and acknowledged that all reports of abuse should be investigated, regardless of whether a formal grievance was filed.
Failure to Complete Required PASARR Level II Assessment
Penalty
Summary
The facility failed to ensure that a PASARR Level II evaluation was completed for a resident admitted with diagnoses including schizoaffective disorder, bipolar type, and probable developmental delay. A PASARR Mental Health Evaluation conducted indicated the need for a Level II assessment for serious mental illness and intellectual or developmental disability. Despite this recommendation and supporting documentation from a hospital discharge summary, there was no evidence in the resident's medical record that a PASARR Level II for intellectual or developmental disability was completed. During interviews, both the Social Services Director and Social Services Coordinator acknowledged they did not request the required assessment and were unaware of when such a request should be made. The Administrator confirmed that the assessment was not completed as required.
Failure to Ensure Resident Access to Functional Hearing Aids
Penalty
Summary
A resident with a history of bipolar disorder was admitted to the facility and was documented as being able to hear adequately with the use of hearing aids. However, progress notes indicated that the resident's hearing aids were not working at the time of admission and subsequently became broken. Despite the resident's repeated reports to staff that the hearing aids did not work and did not fit properly, no effective action was taken to repair or replace them. Staff interviews confirmed that the hearing aids had not fit or worked since admission, and the resident had not worn them for about a week due to their condition. The hearing aids, along with unused batteries, were found stored in a cup at the resident's bedside, and no sound was coming from them. Social services staff were either unaware of the resident's need for hearing aids or acknowledged knowing about the issue but did not make efforts to address it. The Director of Nursing Services stated that staff were expected to report such issues so that social services could intervene, but she was unaware of the problem. As a result, the resident was left without functional hearing aids, requiring others to speak loudly and closely to be understood, which the resident found overstimulating. This lack of action led to the resident not having access to necessary hearing assistance devices.
Failure to Provide Restorative Services for Resident with Limited Mobility
Penalty
Summary
A deficiency was identified when a resident with a history of pleural effusion, who had previously received physical therapy, was not offered restorative services to maintain or improve range of motion (ROM) after discharge from therapy. The resident expressed interest in continuing physical therapy or restorative services during a care conference, and a progress note indicated the resident would be a good fit for a restorative program. Despite this, there was no evidence in the clinical record that restorative services were provided. The resident reported not receiving physical therapy for over two months and not being offered ROM exercises, even though they wished to participate in restorative services. Staff interviews revealed confusion and lack of follow-through regarding the resident's enrollment in restorative services. One CNA believed the resident was receiving restorative care but had not observed participation, while another confirmed the resident was not on the restorative list. The restorative aide stated the resident was discussed for possible inclusion but was not added due to a full caseload. The RN case manager was unsure why the resident was not enrolled after expressing interest, and the regional administrator acknowledged the expectation that residents who express interest should be offered restorative services.
Failure to Follow Transmission-Based Precautions for Resident with C. diff
Penalty
Summary
Staff failed to consistently follow transmission-based precautions for a resident admitted with Clostridioides difficile (c-diff), who was on enteric precautions. Observations revealed that a CNA entered the resident's room without donning personal protective equipment (PPE) and subsequently exited the room, handled a lunch tray, and accessed common areas without performing hand hygiene. The CNA acknowledged awareness of the resident's precaution status but believed PPE was not required for meal delivery and admitted to not washing hands after leaving the room. Further observations showed another CNA provided care to the resident while wearing gloves but without a gown, and admitted to removing PPE before completing all care tasks. Additionally, the resident was observed ambulating in the hallway during a therapy session without PPE, despite being on transmission-based precautions and expected to remain in their room. Interviews with staff confirmed that education on precautions had been provided and signage was posted, but staff did not consistently adhere to the required protocols.
Failure to Properly Prepare Resident for Facility-Initiated Discharge
Penalty
Summary
The facility failed to properly orient and prepare a resident for a facility-initiated discharge, leading to a deficiency in safe discharge practices. Resident 11, who was admitted with diagnoses including depression, anxiety, alcohol abuse, and cannabis dependence, was provided with a list of assisted living facilities via email but was not given sufficient preparation or orientation for discharge. The resident left the facility for over 24 hours and was subsequently discharged against medical advice (AMA) without their medications. Staff 3, an RNCM, stated that the discharge was due to the resident's absence past midnight, while Staff 1, the Administrator, confirmed the discharge was facility-initiated and was unaware that an AMA discharge needed to be initiated by the resident.
Failure to Follow Diabetic Medication Orders
Penalty
Summary
The facility failed to adhere to physician's orders for a resident with diabetes, leading to a deficiency in diabetic medication management. The resident, who was admitted with diagnoses including diabetes, a fracture, and dementia, had specific orders for insulin administration. These orders included administering Humalog insulin based on a sliding scale for capillary blood glucose (CBG) levels, with instructions to notify the physician if CBG levels exceeded 351. However, the facility did not notify the physician on nine occasions when the resident's CBG levels were above this threshold. The deficiency was identified through interviews and record reviews, which revealed that staff members, including an LPN and an RNCM, acknowledged the failure to notify the physician as required. The resident's care plan and medical records indicated the need for close monitoring and communication with the physician, especially given the resident's moderate cognitive impairment and risk for complications from diabetes. Despite these requirements, the facility's inaction in notifying the physician as per the orders placed the resident at risk for unmanaged diabetes complications.
Facility Fails to Provide Palatable Food to Residents
Penalty
Summary
The facility failed to provide palatable food for four out of five sampled residents, which placed them at risk for unmet nutritional needs. The deficiency was identified through observations, interviews, and record reviews. Residents with various medical conditions, including severe protein-calorie malnutrition, Vitamin D deficiency, malnutrition, hepatic encephalopathy, hypertension, chronic kidney disease, and diabetes, reported dissatisfaction with the food quality. Test trays delivered to survey team members on two separate occasions were found to be unpalatable, with issues such as tough and dry chicken fried steak, salty ham, bland noodles, and overcooked carrots. Additionally, the food was not served at an appetizing temperature. Residents expressed their dissatisfaction with the meals, describing them as 'shitty,' tough, spicy, and lacking flavor. Complaints were also documented in Food Committee Meeting Notes, highlighting issues such as overly peppery seasoned potatoes, tough pork, cold and soggy fries, and consistently overcooked meat. Staff members, including the Administrator and DNS, sampled the test trays and confirmed the residents' complaints, noting the poor texture of the potatoes and the blandness of the noodles.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
