Avamere Riverpark Of Eugene
Inspection history, citations, penalties and survey trends for this long-term care facility in Eugene, Oregon.
- Location
- 425 Alexander Loop, Eugene, Oregon 97401
- CMS Provider Number
- 385185
- Inspections on file
- 25
- Latest survey
- March 2, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Avamere Riverpark Of Eugene during CMS and state inspections, most recent first.
A resident with a history of stroke sustained rib fractures and a closed head injury after a shower chair, previously identified as broken and not properly inspected or removed from service, collapsed during use. Facility records showed that required equipment inspections were not completed, and staff failed to communicate or address the chair's unsafe condition before it was used again.
Two residents did not receive proper incontinence and catheter care as required by their care plans and physician orders. One resident was repeatedly found with dried feces on their body and reported not receiving timely care unless they specifically requested it. Another resident with a catheter was not changed or checked for an extended period during a night shift, despite clear orders for care each shift. Staff interviews confirmed lapses in care and delays in responding to resident needs.
The facility failed to follow professional standards for medication administration and equipment sanitization. A resident with bipolar disorder was hospitalized after an RN crushed and administered lithium ER, contrary to guidelines, leading to elevated lithium levels. Another resident's glucometer was improperly sanitized, indicating a lack of adherence to infection control practices.
A resident with bipolar disorder was hospitalized after a nurse crushed and administered lithium ER in pudding, despite instructions not to crush the medication. This resulted in altered mental status and elevated lithium levels, requiring ICU transfer. The error was acknowledged by the RN and DNS, but no documentation was found in the electronic record.
A resident with diabetes experienced a breach of dignity when a nurse performed a blood sugar check and administered insulin in a public dining area without consent. Despite the resident's request for the injection to be given in the arm, the nurse lifted the resident's shirt and injected the insulin into the abdomen, an action acknowledged by two resident care managers as undignified.
A facility failed to include a resident's representative in the care planning process for a resident with stroke and aphasia. Despite the resident's communication challenges, the family member, who was the main contact, did not receive invitations to care conferences due to outdated address information. The facility had not attempted to contact the family member for nine months, and the Social Services Coordinator acknowledged the lack of communication to ensure family involvement.
The facility failed to notify residents, their representatives, and the ombudsman of hospital transfers for three residents, including those with cellulitis, heart failure, seizures, gastroenteritis, and colitis. The lack of transfer notices was confirmed by facility staff.
The facility failed to provide written notice of its bed hold policy to residents or their representatives during hospital transfers, affecting three residents. One resident with cellulitis and heart failure, another with seizures, and a third with gastroenteritis were transferred without receiving the necessary information. Staff members admitted to not understanding the process and lacking training, which was acknowledged by the facility's administration.
The facility failed to provide meaningful activities for two residents, one with a stroke and severely impaired cognition, and another with depression. Despite documented interests and care plans, there was no record of participation in activities for the past month. Observations showed one resident frequently in bed with a muted TV, while the other reported not receiving in-room activities. Staff interviews revealed a lack of awareness and facilitation of activities, leading to a diminished quality of life.
Two residents experienced inadequate assessment and documentation of pressure ulcers. One resident had inaccurately documented sacral ulcers, while observations showed ulcers on the buttocks. Another resident's knee wound, caused by an ill-fitting prosthetic, was misclassified as an abrasion instead of a pressure wound. Staff acknowledged inaccuracies in both cases.
The facility failed to ensure that two cognitively intact residents understood the arbitration agreements they signed. One resident, admitted with muscle weakness, and another with a pressure ulcer, were unaware of signing the agreements, and no explanation was provided. The administrator acknowledged the oversight.
A resident with chronic respiratory conditions was prescribed an antibiotic for an upper respiratory infection without confirming the diagnosis through appropriate diagnostic tests. The facility's Infection Preventionist admitted that the resident did not meet the McGeer's Criteria for antibiotic use, which is used for antibiotic stewardship, leading to a deficiency in care.
The facility failed to notify physicians of condition changes for three residents, including refusals of treatment and medication administration errors. One resident with kidney failure refused daily weights and blood sugar checks without physician notification. Another resident with a stroke was lethargic after medications were crushed and administered improperly, leading to hospitalization. A third resident with cellulitis and heart failure experienced uncontrolled pain and drainage, but the physician was not informed.
The facility did not update care plans for two residents with changing conditions, leading to potential unmet needs. One resident with recurrent UTIs had an outdated care plan, while another with heart failure and severe obesity did not receive personalized care for hygiene and edema. Staff acknowledged the care plans were not revised to reflect the residents' ongoing and increased care needs.
A resident with swallowing difficulties was not properly supervised while eating, as required by their care plan. Staff left the resident unattended in the dining room, leading to a risk of aspiration or choking. Interviews confirmed that close supervision was not provided, as staff were not within arm's length or at the same table as the resident.
The facility failed to adequately assess and monitor the respiratory status of two residents, leading to deficiencies in care. One resident with chronic respiratory conditions did not receive thorough assessments despite ongoing symptoms, while another resident's CPAP machine was not regularly cleaned as required. Staff acknowledged these oversights, which were not documented in nursing notes.
The facility failed to provide adequate staffing, resulting in delayed care for two residents. One resident with severe obesity and diabetes experienced long waits for toileting assistance, while another with quadriplegia had a call light out of reach, delaying care. Staff reported understaffing, especially on weekends, and the DNS's expectations for call light response times were not met.
A facility failed to properly sanitize a community use glucometer between resident uses, placing residents at risk for bloodborne illness. An RN was observed using alcohol prep wipes to clean the glucometer after checking a resident's CBG level, unaware of the proper sanitizing wipes required. Two LPNs later confirmed the correct procedure was not followed.
The facility failed to follow physician orders and care plans for three residents, leading to unmet care needs. One resident did not receive prescribed Morphine on two occasions, another was left unattended in a bathtub and became unresponsive, and a third did not receive prescribed colchicine for 12 days due to pharmacy issues.
Resident Injured After Use of Uninspected Broken Shower Chair
Penalty
Summary
A deficiency occurred when a resident with a history of stroke was injured after a fall from a broken shower chair. The incident took place while a CNA was providing a shower, and the chair collapsed, resulting in the resident sustaining rib fractures, a closed head injury, and a bruise. Prior to the incident, the shower chair had previously come apart during use, and two CNAs had reassembled it. The chair was then placed in the maintenance room, but no work order or clear communication regarding its condition was made. A review of facility records showed that required monthly inspections of shower chairs were not completed in 2024 or 2025. The maintenance lead found the chair in the boiler room without any note or work order and did not take further action. The same chair was later returned to use without proper inspection or repair, leading to the resident's fall and injuries. Staff interviews confirmed lapses in the process for identifying and removing unsafe equipment from service.
Failure to Provide Adequate Incontinence and Catheter Care
Penalty
Summary
The facility failed to provide adequate incontinence and catheter care for two residents. One resident, admitted with a history of stroke and urgency incontinence, was identified as a candidate for scheduled toileting and was cognitively intact. Despite care plan interventions for scheduled toileting and peri care after incontinence episodes, there were multiple instances where the resident was found with dried feces on the body, including the groin, buttocks, and thighs. Staff interviews confirmed that the resident was not fully cleaned after incontinence episodes, and at times, the resident remained in a wheelchair all day without care unless they specifically requested assistance. Staff also reported challenges in cleaning the resident completely, with some instances of refusal, which were communicated to nursing staff as per protocol. Another resident, admitted with chronic venous hypertension and a catheter, had physician orders and care plans directing catheter care each shift. On one occasion, the resident was not provided with incontinence or catheter care during the night shift, resulting in the resident not being changed for nine hours and the catheter bag not being checked. Staff confirmed that the resident's call for assistance was not answered in a timely manner, and care was only provided on the following shift. The administrator acknowledged that the expected care was not provided as required.
Medication Administration and Equipment Sanitization Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of medication administration for two residents, resulting in significant health issues for one. Resident 442, diagnosed with bipolar disorder, was admitted to the facility with a physician's order for several medications, including lithium ER, which should not be crushed. On the morning of May 29, 2024, Staff 28, an RN, crushed and administered Resident 442's medications in pudding, contrary to the medication guidelines. This action led to the resident experiencing altered mental status and elevated lithium levels, necessitating hospitalization and ICU admission. Despite being notified of the resident's lethargic condition, Staff 28 did not assess the resident, and no medication error documentation was found in the resident's electronic record. Additionally, the facility failed to ensure proper sanitization practices for medical equipment. Resident 39, who has diabetes, had their blood sugar level checked by Staff 28 in the dining room. The glucometer used was cleaned with small alcohol prep wipes, which were not the appropriate sanitizing wipes as per facility protocol. Staff 28 was unaware of the correct sanitizing procedure, indicating a lack of adherence to professional standards and training in infection control practices.
Medication Error Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the case of a resident with bipolar disorder who was admitted in April 2024. The resident was prescribed lithium ER, which should not be crushed, chewed, or broken. However, on May 29, 2024, a registered nurse (RN) crushed the resident's lithium medication and administered it in pudding due to the resident's difficulty swallowing pills. This action led to the resident experiencing altered mental status and mildly elevated lithium levels, resulting in hospitalization and transfer to the ICU. The RN and the Director of Nursing Services (DNS) both acknowledged the error, and no documentation of the medication error was found in the resident's electronic record.
Failure to Maintain Resident Dignity During Medication Administration
Penalty
Summary
The facility failed to ensure the dignity of a resident during medication administration. A resident, admitted with a diagnosis of diabetes, was subjected to a blood sugar measurement and insulin injection in a public dining area without their permission. The resident expressed a preference for the insulin to be administered in their arm, but the staff member proceeded to lift the resident's shirt and inject the insulin into the abdomen in front of other residents. This action was acknowledged by two resident care managers as a failure to protect the resident's dignity.
Failure to Include Resident's Representative in Care Planning
Penalty
Summary
The facility failed to ensure the inclusion of a resident's representative in the care planning process for a resident with a history of stroke and aphasia, who was rarely understood and used nonverbal communication. The resident was admitted in December 2023, and subsequent care plan reviews in April and July 2024 indicated that the attendance of the responsible party was marked as not applicable. Despite the resident's communication challenges, the facility did not ensure that the main contact, a family member, was invited to care conferences. The family member, who visited the facility weekly, reported not receiving invitations to these conferences. It was revealed that invitations were sent to an outdated address and returned to the facility, with the last attempt to contact the family member occurring nine months prior. The Social Services Coordinator acknowledged the lack of communication with the resident or the family member to ensure their involvement in the care planning process.
Failure to Notify Required Parties of Hospital Transfers
Penalty
Summary
The facility failed to provide timely notification to residents, their representatives, and the Office of the State Long-Term Care Ombudsman regarding hospital transfers for three residents. Resident 42, admitted with cellulitis and heart failure, was transported to the emergency department due to uncontrolled pain. Despite the completion of a discharge assessment anticipating the resident's return, no transfer notice was provided to the resident, their representative, or the ombudsman. This oversight was acknowledged by the Director of Nursing Services. Similarly, Resident 44, who had a history of seizures, was transported to the hospital without any evidence of a transfer notice being provided to the resident, their representative, or the ombudsman. The facility administrator confirmed the lack of notification. Additionally, Resident 89, admitted with non-infective gastroenteritis and colitis, was discharged to the hospital without a written transfer notice or notification to the ombudsman. The administrator acknowledged this failure as well.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notice of its bed hold policy to residents or their representatives at the time of transfer to a hospital, affecting three residents. Resident 42, admitted with cellulitis and heart failure, was transferred to the emergency department due to uncontrolled pain. There was no documentation that Resident 42 or their representative received information about the bed hold policy. Staff 14, an LPN, admitted to not understanding the process and lacking training on providing bed hold information, which was acknowledged by Staff 2, the Director of Nursing Services. Resident 44, admitted with seizures, was also transferred to the hospital without receiving the bed hold policy. The facility administrator confirmed that neither the resident nor their representative was provided with this information. Similarly, Resident 89, with a diagnosis of noninfective gastroenteritis and colitis, was discharged to the hospital without evidence of a transfer notice or notification to the State Long-Term Care Ombudsman. Staff 27, the Guest Services Coordinator, was unable to contact Resident 89 and documented a late entry.
Failure to Provide Meaningful Activities for Residents
Penalty
Summary
The facility failed to provide meaningful activities to two residents, leading to a diminished quality of life. Resident 37, who was admitted with a diagnosis of stroke and had severely impaired cognition, had a care plan that included interests in gospel music, Christmas, and bible study. Despite these documented interests, there was no record of Resident 37 participating in group or one-on-one activities for the past thirty days. Observations showed Resident 37 frequently lying in bed with the television on but muted. Staff interviews revealed a lack of awareness and assistance in facilitating Resident 37's participation in activities, despite the care plan's directives. Similarly, Resident 21, admitted with a diagnosis of depression, expressed disinterest in group activities and reported not receiving in-room activities. The medical record indicated only one instance of one-on-one activity in the last thirty days. Staff interviews confirmed that Resident 21 preferred staying in bed and that in-room activities were supposed to include electronics, television, music, and one-to-one visits. However, documentation of these activities was lacking, indicating a failure to engage Resident 21 in meaningful activities as per their preferences.
Inadequate Assessment and Documentation of Pressure Ulcers
Penalty
Summary
The facility failed to properly assess and document pressure ulcers for two residents, leading to inaccuracies in their medical records. Resident 13, admitted with muscle weakness, was identified as at risk for pressure ulcers due to incontinence and decreased mobility. Despite a care plan noting skin concerns, an incident report on 9/24/24 mentioned redness and blisters without specifying their location. Subsequent wound evaluations inaccurately documented a sacral ulcer, while observations on 10/9/24 revealed pressure ulcers on the bilateral buttocks. Staff acknowledged the investigation into Resident 13's pressure ulcers was neither accurate nor thorough. Resident 62, with a left below-knee amputation, developed a wound on the left knee initially described as an abrasion from a prosthetic leg. However, the resident and staff later identified it as a pressure wound due to friction from the ill-fitting prosthetic, exacerbated by weight loss. Despite adjustments and added padding to the prosthetic, the wound was misclassified, and staff acknowledged it met the definition of a pressure wound. This misclassification and inadequate assessment contributed to the deficiency in care.
Failure to Ensure Understanding of Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents understood the meaning of an arbitration agreement, which involves resolving disputes with a neutral party rather than in court. This deficiency was identified for two residents who were cognitively intact at the time of signing. Resident 13, admitted with a diagnosis of muscle weakness, was not aware of signing the arbitration agreement, and their family member did not recall any discussion about it. Similarly, Resident 76, admitted with a pressure ulcer, did not remember signing the agreement, and it was not explained to them. The facility's administrator acknowledged the need to ensure residents or their representatives understood the arbitration agreement.
Antibiotic Use Without Indication
Penalty
Summary
The facility failed to ensure that an antibiotic was indicated for use in a resident who was reviewed for respiratory care. The resident, admitted in July 2023, had multiple diagnoses including chronic obstructive pulmonary disease, congestive heart failure, and pulmonary hypertension. On September 22, 2024, the resident exhibited symptoms of a wet productive cough and generalized body aches but tested negative for COVID-19. Despite these symptoms, a new antibiotic order was received on September 24, 2024, for an upper respiratory infection without further diagnostic testing to confirm the infection or rule out complications from the resident's existing respiratory conditions. The Infection Preventionist acknowledged that the resident did not meet the McGeer's Criteria for an upper respiratory infection, which the facility used for antibiotic stewardship. The resident was started on an antibiotic without a chest x-ray or other lab tests to confirm the diagnosis. This oversight placed residents at risk for antibiotic-resistant organisms, as the facility did not adhere to its established criteria for antibiotic use, leading to the deficiency noted in the report.
Failure to Notify Physicians of Resident Condition Changes
Penalty
Summary
The facility failed to notify physicians regarding refusals and changes in condition for three residents, which placed them at risk for lack of physician involvement. Resident 26, admitted with kidney failure, had physician orders for daily weights and blood sugar checks, with specific instructions to notify the physician of certain changes. However, from late September to early October, the resident refused these checks, and there was no documentation that the physician was informed of these refusals. Staff confirmed that the physician was not notified during this period. Resident 442, admitted with a stroke, had a change in condition when medications were crushed and administered inappropriately, leading to lethargy and hospitalization with elevated lithium levels. Despite being notified of the resident's lethargy, staff did not assess the resident or notify the physician. Similarly, Resident 42, with cellulitis and heart failure, experienced changes in condition on two occasions, including uncontrolled pain and drainage, but there was no indication that the physician was notified. Staff acknowledged the lack of physician notification in these instances.
Failure to Update Care Plans for Residents with Changing Conditions
Penalty
Summary
The facility failed to complete and update comprehensive care plans within the required timelines for two residents, leading to potential unmet needs. Resident 38, admitted in August 2022 with kidney disease and recurrent UTIs, reported chronic bladder discomfort and urinary urgency. Despite being diagnosed with six UTIs in 2023, the care plan initiated on July 21, 2023, was not revised to address these recurring issues. Staff confirmed that the care plan interventions had not been updated since its initiation, failing to reflect the resident's ongoing condition. Resident 42, admitted in June 2024 with heart failure and severe obesity, required substantial assistance with toileting hygiene and monitoring for heart failure signs, including edema. The care plan revised on October 3, 2024, did not adequately address the resident's personal hygiene needs or the increased care needs following a September 2024 hospitalization. The resident expressed that staff often left without offering necessary assistance, and the care plan was not personalized to meet the resident's specific needs, as acknowledged by the DNS and Administrator.
Failure to Supervise Resident During Meal
Penalty
Summary
The facility failed to provide adequate supervision to a resident with known swallowing difficulties, leading to a risk of aspiration or choking. Resident 292, who was admitted with dementia and swallowing difficulties, was not properly supervised while eating a peanut butter and jelly sandwich. On the evening of March 14, 2024, Staff 24 assisted the resident into the Central Dining Room and provided the sandwich before leaving to chart at the Central Nursing Station. Staff 24 claimed to have asked Staff 26, an LPN, to supervise the resident, but Staff 26 was also charting at the Central Nursing Station and was unaware that the resident was eating. Interviews with various staff members, including a CNA, LPN-Resident Care Manager, and ST-Rehab Manager, revealed that close supervision required staff to remain within arm's length or sit at the same or an adjoining table with the resident. However, Staff 26 did not supervise the resident as required. The Director of Nursing Services confirmed that the dining room could not be observed from the Central Nursing Station, acknowledging that the resident did not receive the necessary close supervision while eating.
Deficiencies in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to thoroughly assess and monitor the respiratory status of two residents, leading to deficiencies in their care. Resident 17, who was admitted with chronic obstructive pulmonary disease, congestive heart failure, and pulmonary hypertension, experienced a moist cough and required continuous oxygen. Despite these symptoms, thorough respiratory assessments were not documented after 9/25/24, and the resident continued to exhibit respiratory symptoms without adequate monitoring. Staff acknowledged the lack of thorough assessments, which were expected to include lung sounds, cough, temperature, and oxygen saturation. Resident 42, diagnosed with sleep apnea, had a care plan requiring the use of a CPAP machine, which was to be cleaned daily. However, there were no nursing notes documenting the care of the CPAP machine, and the resident reported that the machine was rarely cleaned. Staff indicated that the task was often not completed due to the resident's request to return later when the machine was not in use. The DNS acknowledged the need for the CPAP machine to be cleaned as ordered, despite its frequent use.
Staffing Deficiencies Lead to Delayed Care for Residents
Penalty
Summary
The facility failed to provide sufficient staffing for two residents, leading to unmet needs and delayed care. Resident 42, who was admitted with heart failure, diabetes, and severe obesity, required substantial assistance with toileting hygiene. Despite a care plan indicating the need for intermittent supervision, Resident 42 frequently waited up to an hour for assistance, as confirmed by both the resident and staff members. Observations showed prolonged call light response times, and staff reported that the hall was understaffed, particularly on weekends. The administrator acknowledged that staffing needs based on Resident 42's acuity were not met, and call light response times needed improvement. Resident 76, diagnosed with quadriplegia, was dependent on staff for all care and required a sip and puff call light to request help. However, the call light was not within reach, and staff failed to ensure it was properly placed. On one occasion, a CNA turned off the call light without providing care or repositioning it, resulting in a delay in assistance. Staff reported being mandated to work extra shifts and noted that the facility did not account for the high number of residents requiring two-person assistance when determining staffing levels. The DNS expected call lights to be answered within 12 to 15 minutes, but this standard was not met for Resident 76.
Improper Sanitization of Glucometer Between Uses
Penalty
Summary
The facility failed to ensure proper sanitization of a community use glucometer between resident uses, specifically for a resident with diabetes who was admitted in February 2024. On October 9, 2024, a registered nurse (RN) was observed checking the resident's capillary blood glucose (CBG) level in the dining room and subsequently cleaning the glucometer with small alcohol prep wipes. The RN stated that she always used alcohol prep wipes for sanitizing the glucometer and was unaware of any other sanitizing wipes. Later, two licensed practical nurses (LPNs) confirmed that the glucometer should be sanitized with the proper sanitizing wipes, indicating a failure in following the correct infection prevention and control procedures.
Failure to Follow Physician Orders and Care Plans
Penalty
Summary
The facility failed to follow physician orders and care plans for three residents, leading to unmet care needs. Resident 9, diagnosed with chronic pain syndrome, did not receive prescribed Morphine on two occasions due to the facility running out of the medication. This resulted in the resident experiencing increased pain and distress. The facility staff acknowledged the failure to administer the medication as ordered by the physician. Resident 3, diagnosed with vascular dementia and requiring assistance with ADLs, was left alone in a bathtub for over an hour, during which the resident became unresponsive. The care plan, which required one-person assistance with bathing, was not followed. Staff interviews confirmed that the resident was left unattended and that the responsible staff member no longer worked at the facility. Resident 5, diagnosed with fibromyalgia, did not receive the prescribed colchicine for 12 days due to issues with acquiring the medication from the pharmacy. The DNS acknowledged the failure to administer the medication as ordered.
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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