Avamere Transitional Care At Sunnyside
Inspection history, citations, penalties and survey trends for this long-term care facility in Salem, Oregon.
- Location
- 4515 Sunnyside Road Se, Salem, Oregon 97302
- CMS Provider Number
- 385189
- Inspections on file
- 26
- Latest survey
- June 11, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Avamere Transitional Care At Sunnyside during CMS and state inspections, most recent first.
A medical assistant, not certified as a medication aide, administered medications to residents after being scheduled through an agency to fill a CMA shift. The error was discovered only after the shift ended, when nursing staff questioned her qualifications and confirmed she was not permitted to administer medications under state law or facility policy.
Staff did not consistently sign narcotic log books to verify controlled drug counts on multiple medication carts, resulting in numerous missed verifications. The DNS confirmed that narcotic counts should always be verified and signed by two nurses or CMAs, but this was not done as required.
Staff and residents reported ongoing shortages of bariatric sheets and towels, resulting in delays in bed changes and care for multiple bariatric residents. The issue persisted for several months despite being reported to management, with staff often unable to find appropriate linens and residents experiencing discomfort due to lack of proper bedding.
A resident who primarily speaks Spanish was not provided with adequate translation services during care interactions, resulting in communication barriers and the resident being unable to fully participate in health care decisions. Staff did not consistently use translation devices as outlined in the care plan, and the resident's preferences regarding blood pressure monitoring were not understood or respected.
A resident with chronic pain and PTSD reported delayed administration of pain medication and felt disrespected after voicing concerns to the DNS, who responded dismissively. The resident completed a grievance form, but did not receive any follow-up or written resolution, and key staff were unaware of the grievance, indicating the facility did not follow its grievance policy.
A resident with multiple chronic conditions was transferred to the hospital, but neither the resident nor their representative received the required written bed hold notification, including information about reserved bed hold payment, at the time of transfer. Facility staff confirmed the omission, citing the resident's Medicaid payer status, despite policy requiring written notice for all residents.
A resident with COPD and diabetes was repeatedly observed receiving oxygen via nasal cannula without any documented physician orders or instructions for equipment maintenance. Staff confirmed the absence of current orders, resulting in a failure to provide respiratory care and services under physician direction.
A resident with chronic pain and severe osteoarthritis experienced ongoing, inadequately managed pain despite receiving scheduled gabapentin and acetaminophen. The resident reported frequent breakthrough pain and stated that requests for additional pain relief were not addressed, with no documentation or provider communication found regarding these concerns.
The facility experienced significant staffing shortages, leading to prolonged call light response times and inadequate care for residents. Several residents reported sitting in wet and soiled briefs due to delays in assistance, with staff confirming that the facility had been short-staffed since the summer. The issue affected residents' ADL care, particularly on weekends and during shifts with high acuity residents.
Several residents in the facility were provided with improperly sized incontinence briefs, leading to discomfort and potential skin breakdown. Despite complaints, the facility continued to use briefs based on height and weight, disregarding individual needs. Additionally, a resident with a Stage 4 pressure wound was not provided with necessary wet wipes for gentle care, leading to further discomfort.
Two residents experienced violations of dignity and privacy in a facility. One resident waited nearly an hour for assistance after using a commode, causing distress. Another resident faced an unauthorized room and body search, leading to feelings of humiliation. These incidents highlight a failure to respect residents' rights.
A resident with CHF experienced significant weight gains over several days, which were not reported to the physician as required by facility policy. Despite the facility's guidelines and the American Heart Association's recommendations, nursing staff failed to notify the physician of these changes, leading to the resident being sent to the hospital for evaluation after a delayed report.
A resident with morbid obesity and diabetes did not receive their requested meals on multiple occasions. On one occasion, the resident ordered specific items but did not receive all of them, and on another, the resident was not given a menu to select meals, resulting in receiving unwanted food. A CNA confirmed this was a frequent issue, and the Dietary Manager was unaware of the resident's preferences due to being new to the position.
Unqualified Staff Administered Medications
Penalty
Summary
The facility failed to ensure that only qualified staff administered medications to residents, as required by state regulations and facility policy. Specifically, a staffing coordinator posted a request for Certified Medication Aides (CMAs) to pass medications, but an agency medical assistant, who was not a CMA and not permitted by Oregon law to administer medications in a nursing facility, signed up for the shift and administered medications on two floors. The error was discovered only at the end of the shift when nursing staff questioned the individual's qualifications and verified her credentials, revealing she was a medical assistant, not a CMA. The facility's policy stated that only licensed or state-permitted individuals could prepare, administer, and document medication administration. Despite this, the medical assistant worked an entire eight-hour shift administering medications under the mistaken belief that she was allowed to do so if supervised by a nurse or physician. The incident was triggered by a public complaint and confirmed through staff interviews and record review, establishing that unqualified personnel had administered medications to residents.
Failure to Maintain Accurate Narcotic Drug Records
Penalty
Summary
Facility staff failed to ensure that narcotic drug records were properly maintained and that an account of all controlled drugs was accurately kept for all four medication carts reviewed. During the review of narcotic log books on multiple medication carts across both the South and North halls, it was found that staff did not sign to verify the accuracy of the narcotic count on numerous occasions. Specifically, there were multiple instances where required signatures were missing, with counts ranging from 36 to 94 missed signatures out of 180 to 186 counting opportunities per log book. At the time of the survey, the Director of Nursing Services (DNS) confirmed the absence of required signatures in the narcotic log books and acknowledged that the narcotic count should always be verified and signed by two nurses or Certified Medication Aides (CMAs). The lack of proper verification and documentation was observed and confirmed during the survey process.
Ongoing Shortage of Bariatric Linens and Towels
Penalty
Summary
The facility failed to ensure sufficient supplies, specifically bariatric sheets and towels, were available to meet the needs of residents on one of two floors reviewed. Multiple staff members, including CNAs and the Maintenance Director, reported ongoing shortages of bariatric linens and towels since February 2025. Staff described frequent situations where they were unable to find appropriate linens in the North Hall linen closet, resulting in delays in changing residents' beds and providing care. These shortages were reported to management and housekeeping, but the issues persisted over several months. Residents affected by the shortage reported discomfort and inconvenience, such as not having the correct size sheets for bariatric beds, sheets slipping off mattresses, and waiting extended periods before their bedding could be changed. Staff confirmed that the problem was particularly acute on weekends and during times when multiple bedbound bariatric residents required care. The facility administrator acknowledged awareness of the ongoing issue with insufficient linens to meet all residents' needs.
Failure to Ensure Communication in Resident's Preferred Language
Penalty
Summary
A deficiency occurred when a Spanish-speaking resident with hypertension was not fully informed about their health status and care in a language they could understand. The resident's care plan indicated that translation services would be available, but multiple incidents showed that staff did not consistently use these services. The resident reported that some staff were impatient and did not take the time to understand or communicate with them effectively. On one occasion, a CNA told the resident to stop talking while attempting to take their blood pressure, and did not use the tablet translator as required. The resident expressed frustration at not being respected or understood, particularly regarding their preference for a manual blood pressure cuff instead of the tower monitor. Staff interviews confirmed that translation devices were not used during these interactions, and the CNA involved acknowledged being blunt and not utilizing the translator. The Director of Nursing Services stated that staff were expected to use translator tablets but had not provided recent training on communicating with non-English speaking residents, assuming it was covered during orientation. These actions and inactions resulted in the resident not being able to fully participate in their own health care decisions due to language barriers.
Failure to Communicate Grievance Resolution to Resident
Penalty
Summary
A resident with chronic pain and PTSD, who was cognitively intact at admission, reported that nursing staff failed to administer prescribed pain medication in a timely manner. After waiting for an extended period and missing a physical therapy session due to pain, the resident attempted to voice concerns to the Director of Nursing Services (DNS), who responded dismissively and directed the resident to leave her office. The resident described the DNS as rude and disrespectful, and subsequently completed a grievance form with the assistance of staff, which was submitted to the administrator's office. Despite the facility's grievance policy requiring prompt action and communication of grievance resolutions to residents, the resident did not receive any follow-up or written resolution regarding the grievance. Multiple staff members, including the Social Service Director and the Administrator, were unaware of the grievance submission until after the fact. The grievance process was not followed, and the resident's concerns about pain management and staff conduct were not addressed in accordance with facility policy.
Failure to Provide Written Bed Hold Notification at Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed hold notification, including information about reserved bed hold payment, to a resident or the resident's representative at the time of transfer to the hospital. The facility's policy, dated 10/2022, requires that all residents, regardless of payer source, receive written notice about bed hold and return policies at the time of transfer. The resident involved had a history of congestive heart failure, COPD, and respiratory failure, and was transferred to the hospital. Review of the clinical record showed no evidence that the required written notice was given at the time of transfer. Facility staff confirmed that the notification was not provided because the resident's payer source was Medicaid, and acknowledged that the written policy should have been followed.
Failure to Provide Physician-Ordered Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care and services in accordance with physician orders for a resident with COPD and diabetes. The resident was admitted with a care plan indicating the need for oxygen via nasal cannula as needed, along with interventions to monitor for signs of respiratory compromise. Observations over several days showed the resident receiving oxygen through a nasal cannula on multiple occasions, both in bed and during routine care. Staff interviews confirmed that the resident regularly used oxygen while in bed. Despite the ongoing administration of oxygen, a review of the clinical record revealed there were no documented physician orders for oxygen administration, nor were there orders specifying how often the oxygen filter should be cleaned, checked, or how often the tubing should be changed. Staff confirmed the absence of current physician orders for oxygen. This lack of documentation and physician oversight constituted a failure to provide respiratory care and services as required.
Failure to Address Resident's Breakthrough Pain and Provider Communication
Penalty
Summary
The facility failed to provide appropriate pain management for a resident with chronic pain and severe osteoarthritis. The resident was admitted with diagnoses including osteoarthritis of the hip and knee, and chronic pain. Physician documentation recommended continuing pain management with PRN acetaminophen, and the care plan included non-pharmaceutical interventions and reporting pain complaints to nursing staff. The resident's quarterly assessment indicated almost constant pain affecting sleep, daily activities, and therapy, with a self-reported pain level of seven out of ten. Medication orders for gabapentin and scheduled acetaminophen were administered as prescribed. Despite these interventions, the resident reported ongoing breakthrough pain and stated that requests for additional pain relief had not been addressed. The resident indicated that topical creams were ineffective and that a request for additional medication made weeks prior had not resulted in any action. Review of the clinical record revealed no documentation or communication with the provider regarding the resident's pain management needs or clarification of the PRN acetaminophen order. The Director of Nursing confirmed that there was no evidence the physician had been contacted for clarification, as would be expected.
Staffing Shortages Lead to Prolonged Call Light Response Times
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in prolonged call light response times and inadequate care for several residents. Resident 1, who was admitted with diagnoses including diabetes and renal disease, required assistance for all ADL care needs and a mechanical lift for transfers. Despite these needs, Resident 1 experienced call light response times of 30 minutes or longer, leading to instances of sitting in wet and soiled briefs. Staff and the resident reported ongoing concerns about staffing shortages and long wait times, which had been an issue since the summer months. Resident 2, admitted with a stroke and depression, was on a toileting program due to incontinence and required assistance for ADL care. The resident reported sitting in a wet and soiled brief for over 20 minutes on multiple occasions due to long call light response times. Staff confirmed these concerns, attributing the delays to a lack of sufficient staffing. Similarly, Resident 3, who required assistance with toileting hygiene, reported sitting on a bedside commode for extended periods without assistance, sometimes up to an hour, due to staffing shortages. Resident 13, with a history of stroke and anxiety, also experienced long call light response times, sometimes upwards of 40 minutes, resulting in sitting in wet briefs. The facility's staffing issues were further highlighted by a review of Direct Care Staff Daily Reports, which showed that state minimum staffing requirements were not met for 74 out of 90 days. Staff interviews consistently indicated that the facility had been short-staffed since July 2024, affecting the quality of care provided to residents, particularly on weekends and during shifts with high acuity residents.
Improper Sizing of Incontinence Briefs and Inadequate Wound Care
Penalty
Summary
The facility failed to accommodate the needs and preferences of several residents by providing incontinence briefs that were improperly sized, leading to discomfort and potential skin breakdown. Resident 1, who was admitted with diagnoses including diabetes and renal disease, was switched to a smaller brief size that was too tight and caused red marks on the skin. Despite complaints from the resident and observations from staff that the new briefs were uncomfortable and did not fit properly, the facility continued to use the briefs based solely on height and weight measurements, disregarding the resident's specific needs and preferences. Similarly, Resident 13, who had a history of stroke and anxiety, was also provided with a new brief size that was too small and tight around the thighs and crotch area. The resident expressed dissatisfaction with the new briefs, but was informed that the size was appropriate based on height and weight. The facility's management did not consider the resident's waist or lower body size, and residents were told to purchase their own briefs if they were unhappy with the provided size. Resident 15, diagnosed with morbid obesity and anxiety, experienced similar issues with the new brief size, which was too small and caused discomfort. The resident reported these concerns to management but was advised to buy personal supplies. Additionally, Resident 6, who had a Stage 4 pressure wound, was not provided with wet wipes for incontinence care, despite the need for gentle care due to skin breakdown. The facility had moved to using washcloths instead of wet wipes, and Resident 6 was not initially included on the list of residents approved for wet wipes, leading to further discomfort and potential harm.
Violation of Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure the dignity and respect of two residents, leading to a deficiency in their care. Resident 3, who was admitted with diagnoses including morbid obesity and depression, experienced a delay in receiving assistance after using the bedside commode. Despite turning on the call light, the resident waited nearly an hour for help, causing physical discomfort and emotional distress. The delay was attributed to staff being occupied with other duties, and the resident expressed frustration and upset over the repeated occurrences of such incidents. Resident 15, admitted with morbid obesity and anxiety, faced a violation of privacy and dignity when staff conducted a room and body search without proper consent. The resident, who had a history of non-compliance with smoking paraphernalia, was found with a lighter and a pill in her possession. Following this, staff searched the resident's room and conducted a body search without obtaining permission, leading to the resident feeling humiliated and targeted. The staff involved were uncomfortable with the search, and the resident was extremely upset by the invasion of privacy. Both incidents highlight the facility's failure to uphold residents' rights to a dignified existence and self-determination. The lack of timely assistance for Resident 3 and the unauthorized search of Resident 15's room and person demonstrate a disregard for the residents' dignity and respect. These actions resulted in emotional distress and a diminished quality of life for the residents involved.
Failure to Notify Physician of Significant Weight Gain in Resident with CHF
Penalty
Summary
The facility failed to notify the physician regarding a significant change in condition for a resident diagnosed with Congestive Heart Failure (CHF) and a below-the-knee amputation. The resident experienced multiple instances of significant weight gain over a short period, which were not reported to the physician as required by the facility's policy. Specifically, the resident had a 4.9-pound weight gain in 24 hours, a 10.2-pound weight gain over seven days, a 4-pound weight gain in 24 hours, and a 3.2-pound weight gain in 24 hours, none of which were communicated to the physician. Interviews with staff revealed that the nursing staff did not notify the physician of these weight changes, despite the facility's policy and the American Heart Association's recommendations to report such changes. The Director of Nursing Services (DNS) and the Medical Director confirmed that the physician was not notified as expected. The resident was eventually sent to the hospital for evaluation of lower extremity swelling after a significant weight gain was finally reported.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of a resident, identified as Resident 3, who was admitted in 2020 with diagnoses including morbid obesity and diabetes. On December 27, 2024, Resident 3 ordered a meal that included barbecue country ribs, scalloped potatoes, mixed vegetables, fruit salad, two strawberry kiwi juices, and two diet lemon sodas. However, the resident received only one of each beverage and no fruit salad. The resident expressed that this was a frequent issue, and a Certified Nursing Assistant (CNA) confirmed that the resident often did not receive what was requested. Further observations on December 31, 2024, revealed that Resident 3 received a breakfast that was not ordered, as the resident was not provided with a menu on the previous day to make selections. The CNA confirmed that this was a common occurrence. The Dietary Manager, identified as Staff 25, stated that CNAs were responsible for ensuring residents completed menus for the next day's meals. Staff 25 was unaware of the resident's unmet requests and preferences, as she was new to the position and still learning the dietary meal ticket system.
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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