Belmont Care And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Portland, Oregon.
- Location
- 812 Se 48th Avenue, Portland, Oregon 97215
- CMS Provider Number
- 385277
- Inspections on file
- 23
- Latest survey
- March 5, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Belmont Care And Rehabilitation during CMS and state inspections, most recent first.
The facility did not promptly address grievances from the Resident Council regarding missing clothing items. Despite residents raising concerns in meetings, no resolutions were filed, and no grievances were recorded. The Administrator acknowledged the failure to address these complaints within the expected timeframe.
The facility did not have a system to deliver mail on Saturdays, contrary to its policy. A resident with chronic venous hypertension and moderate cognitive impairment reported not receiving mail on Saturdays. Staff interviews revealed uncertainty about mail distribution, and the administrator confirmed mail was not distributed unless requested.
The facility failed to provide necessary social services and dental care for four residents, impacting their mental, psychosocial, and physical well-being. Residents with mental health issues did not receive comprehensive assessments or one-to-one support, and those needing dental care did not receive timely referrals, despite clear indications and requests.
The facility failed to follow proper infection control protocols for laundry handling. Staff were observed transporting clean laundry uncovered and soiled linens unbagged, contrary to CDC guidelines and facility policy. This practice increased the risk of contamination.
A resident with vascular dementia in a persistent vegetative state was found to be living in a room that lacked a homelike environment. The room, shared with three other residents, was cluttered with medical supplies, leaving little space for personal belongings. A family member and a CNA noted the room's resemblance to a storage area, and the facility's administrator acknowledged the issue.
The facility failed to promptly resolve grievances for two residents regarding missing personal property. One resident, with diabetes, reported missing pants but no grievance was filed or investigated. Another resident, with congestive heart failure, reported missing pants during a Resident Council meeting, but the grievance was not recorded or addressed in a timely manner. Staff acknowledged the oversight and the need for proper grievance documentation and investigation.
A resident with a history of alcohol abuse and psychotic disorder verbally abused other residents, including those with quadriplegia, anxiety, heart failure, major depression, paraplegia, and PTSD. The incidents involved aggressive and threatening behavior, with staff intervening but unable to prevent the abuse. The facility's policy prohibits such abuse, yet it failed to protect the residents from these incidents.
The facility failed to report allegations of verbal abuse within the mandated timeframe. A resident returned to the facility and threatened staff and other residents, but the incident was not reported to the state agency until well after the required two-hour window. The Director of Nursing Services confirmed the late submission of the report, acknowledging the failure to adhere to the facility's reporting policy.
A resident reported $1,500 missing, but the facility failed to conduct a thorough investigation. The administrator confirmed the report with a family member but did not interview all relevant staff or offer a search of the resident's belongings. Staff members were aware of the issue but did not follow up adequately, leading to a deficiency in the facility's investigation process.
The facility failed to ensure accurate MDS assessments for two residents, leading to an inaccurate representation of their cognitive and mood status. One resident's assessments lacked evaluations for cognitive status and depression, despite being alert and oriented. Another resident was inaccurately documented as being in a vegetative state, although they could respond verbally. Staff confirmed these oversights, highlighting a failure in communication and assessment accuracy.
A resident with a diagnosis of delusional disorders was admitted without a completed PASARR Level II screening, despite the PASRR Level 1 form indicating the need for further mental health evaluation. The facility's Social Services staff was unaware of the requirement, and the DNS expected referrals to be completed within a week, which did not occur.
A facility failed to follow a resident-centered care plan requiring two staff members for bed mobility assistance. Despite the resident's cognitive intactness and specific care plan instructions, an agency CNA attempted to reposition the resident alone, leading to the resident's discomfort and preference not to have the CNA in their room again. This incident highlights a breach in adhering to the care plan, potentially affecting the resident's safety.
The facility failed to provide individualized activity programs for two residents, leading to a deficiency in care. One resident, nonverbal and dependent on staff, was not provided with preferred activities like music and television, while another resident with vascular dementia lacked engagement in preferred activities. The Activity Director admitted to not fulfilling care plan requirements, and the Administrator acknowledged the need for more sensory and social opportunities.
A facility failed to provide trauma-informed care for a resident with PTSD, lacking documentation of individualized interventions and triggers in the care plan. Despite the resident's ability to articulate their triggers, such as feeling trapped and being in groups, staff were unaware and did not document these triggers. The facility administrator acknowledged the absence of expected interventions to mitigate re-traumatization.
The facility failed to provide necessary dental services for two residents, one with vascular dementia and another with diabetes, despite clear indications of dental issues in their care plans and requests for dental care. Staff responsible for scheduling dental appointments were unaware of the residents' needs, resulting in unmet dental care requirements.
A resident with a history of falls had a loose mobility bar on their bed, which had been reported to staff but remained unrepaired for months. The Maintenance Director confirmed the bar was broken and had not been reported for repair. The facility's policy required regular maintenance of assistive devices, which was not followed, leading to a deficiency.
A resident with vascular dementia in a persistent vegetative state did not receive necessary grooming assistance as per their care plan. Despite a physician's order for hair removal cream, staff failed to apply it, resulting in significant facial hair growth. A family member expressed disappointment, and staff interviews revealed a lack of action due to nervousness and oversight.
The facility failed to maintain proper sanitation in the garbage area, with one dumpster lid left open and medical gloves scattered outside. An untied trash bag emitted an odor and contained used medical supplies, confirmed by the DNS.
A resident with alcohol-induced psychotic disorder verbally abused another resident with chronic respiratory failure, using offensive language near the nurses' station. The victim reported feeling unsafe, and a CNA confirmed the aggressor's frequent use of offensive language. The DNS acknowledged the incident after reviewing video footage and noted the aggressor's continued abusive behavior.
A resident with congestive heart failure did not receive scheduled bathing assistance on two occasions, leading to a week without necessary care. The resident confirmed the lack of assistance, and an LPN verified that the showers were not provided or attempted as per the records.
Failure to Address Resident Council Grievances on Missing Clothing
Penalty
Summary
The facility failed to promptly respond to grievances and complaints from the resident council, specifically regarding unresolved missing clothing items. During a Resident Council meeting, several residents expressed concerns about missing clothing, which had been previously raised in a meeting months earlier. However, there was no resolution filed with the minutes of the earlier meeting, and no grievances were recorded in the Grievance Book for that period. This indicates a lack of follow-through in addressing the residents' concerns as per the facility's policy. The facility's policy requires that issues raised during Resident Council meetings be distributed to the relevant departments, with resolutions provided within ten days. However, the Activities Director was unable to locate any resolution for the missing clothing issue from the earlier meeting, and the Social Services Director reported no grievances filed for the subsequent month. The Administrator acknowledged that the complaints were not addressed promptly, highlighting a breakdown in the process meant to ensure resident concerns are resolved in a timely manner.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to have a system in place to deliver mail on Saturdays, which was a deficiency identified during a survey. According to the facility's Mail and Electronic Communication Policy from May 2017, mail and packages should be delivered to residents within 24 hours of delivery on the premises, including Saturdays. However, during a Resident Council meeting, a resident admitted in March 2021 with chronic venous hypertension and moderate cognitive impairment reported not receiving mail on Saturdays. Interviews with staff revealed uncertainty about mail distribution on Saturdays, and the facility administrator confirmed that while mail arrived on Saturdays, it was not distributed to residents unless specifically requested.
Deficiency in Social Services and Dental Care
Penalty
Summary
The facility failed to provide medically-related social services to help residents achieve the highest possible quality of life, specifically in addressing mental and psychosocial needs and dental care. Four residents were affected by this deficiency. Resident 3, who was admitted with anxiety, major depression, and substance abuse, had no comprehensive assessment of mental and psychosocial needs, including trauma triggers. Despite having a care plan that required one-to-one support, the social services staff did not conduct these visits and failed to document or address the resident's frequent behavioral issues. Resident 26, diagnosed with PTSD, bipolar disorder, and substance abuse, also lacked a comprehensive assessment of mental and psychosocial needs. The care plan included interventions for inappropriate behaviors and ineffective coping, but the social services staff did not conduct one-to-one visits or identify interventions for stressful behaviors. The resident's initial trauma assessment tools were not incorporated into the care plan, and there was no documentation of triggers for PTSD. Residents 16 and 22 both required dental care, as indicated by their MDS assessments, which noted obvious or likely cavities or broken teeth. Despite requests from family members and the residents themselves, no dental referrals were made by the social services staff. The administrator expected the social services staff to schedule dental appointments, but this was not done, leaving the residents without necessary dental treatment.
Inadequate Laundry Handling Practices
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols regarding the transportation of clean and soiled laundry. Staff 7 was observed delivering clean laundry to residents' rooms by carrying it draped over her bare arm without any covering, which is against the guidelines set by the CDC and the American Healthcare Association. The Laundry Manager, Staff 8, also transported clean linens in an uncovered plastic bin, acknowledging the difficulty in using the available covered cart due to its awkwardness. This practice was contrary to the facility's expectations and increased the risk of contamination. Additionally, the facility did not follow proper procedures for handling soiled linens. Staff 16 was observed transporting unbagged wet towels and shower sheets on a reclining shower chair from a resident's room to the shower room. This action was in violation of the facility's policy and CDC guidelines, which require soiled linens to be bagged or contained at the point of collection. Staff 16 admitted to not placing the dirty linens in a bag before transporting them, which was not in line with the expected protocol as stated by Staff 2, the Director of Nursing Services.
Failure to Provide Homelike Environment for Resident
Penalty
Summary
The facility failed to provide a homelike environment for a resident diagnosed with vascular dementia and in a persistent vegetative state. The resident's room, shared with three other residents, was observed to have limited space for personal belongings. The room contained a cork board with medical information and a small bedside table with personal hygiene supplies. Storage shelves in the room were filled with medical and incontinence supplies belonging to the resident's roommates, leaving little room for personal items. A family member expressed that the room resembled a storage area and was depressing, indicating there was no space to bring in personal items for the resident's happiness or wellness. A CNA confirmed that the room had been used to store supplies for a long time, with the resident's closet being the only available space for personal items. The facility's administrator acknowledged the lack of space for personal items and agreed that the room was not homelike.
Failure to Resolve Resident Grievances Promptly
Penalty
Summary
The facility failed to promptly resolve grievances related to missing personal property for two residents. Resident 22, who was admitted with a diagnosis of diabetes and was cognitively intact, reported missing a pair of pants gifted by a family member. Despite mentioning the issue to staff, no grievance was filed, and no investigation was conducted. Staff members were either unaware of the complaint or did not take appropriate action to document and address the grievance. The facility's grievance officer and administrator acknowledged that a grievance form should have been completed and an investigation conducted. Similarly, Resident 2, admitted with congestive heart failure, reported missing two pairs of pants during a Resident Council meeting. Although advised to file a grievance, no grievance was recorded in the facility's Grievance Book for the relevant period. The grievance officer later found the grievance form among his pending tasks, indicating a delay in addressing the issue. The administrator expected to be informed of grievances within 24 hours to ensure timely resolution, which did not occur in this case.
Failure to Protect Residents from Verbal Abuse
Penalty
Summary
The facility failed to protect residents from verbal abuse by another resident, identified as Resident 41, who had a history of alcohol abuse and alcohol-induced psychotic disorder. On multiple occasions, Resident 41 verbally abused other residents, including Resident 3, Resident 23, and Resident 26. These incidents occurred when Resident 41 returned to the facility and engaged in aggressive and threatening behavior, using abusive language towards both staff and residents. The incidents were documented by staff, and grievance forms were completed for the affected residents, who appeared visibly upset and verbally abused. Resident 3, who has quadriplegia and anxiety, was threatened by Resident 41, causing Resident 3 to feel unsafe and verbally abused. Similarly, Resident 23, with diagnoses of heart failure and major depression, was verbally attacked by Resident 41, who accused them of being a murderer. Resident 26, who has paraplegia and PTSD, was also subjected to verbal abuse by Resident 41, who used derogatory language and threatened them with a grabber stick. These interactions were witnessed by staff, who intervened but were unable to prevent the verbal abuse from occurring. The facility's policy on recognizing signs and symptoms of abuse/neglect strictly prohibits all types of resident abuse, including verbal abuse. Despite this policy, the facility failed to protect the residents from verbal abuse by Resident 41, who had a known history of aggressive behavior, particularly when under the influence of alcohol. The incidents were confirmed by staff and the facility administrator, who acknowledged the verbal abuse and the expectation that all residents should be free from such treatment.
Failure to Timely Report Allegations of Verbal Abuse
Penalty
Summary
The facility failed to report allegations of verbal abuse within the mandated timeframe for four sampled residents. The facility's policy required all personnel to report any signs and symptoms of abuse immediately to their supervisor or the director of nursing services, and to report allegations of abuse to the state agency within two hours. However, an incident occurred on 6/18/24 at 8:00 PM, where a resident returned to the facility and verbally and physically threatened staff and three other residents. This incident was not reported to the state agency until 6/20/24 at 11:23 AM, which was beyond the required two-hour reporting timeline. The Director of Nursing Services confirmed that the Facility Reported Incident for the allegations was submitted late, acknowledging the failure to adhere to the reporting policy.
Failure to Investigate Resident's Missing Money
Penalty
Summary
The facility failed to conduct a thorough investigation into the alleged misappropriation of a resident's personal property, specifically $1,500 reported missing by a resident who was cognitively intact. The resident, admitted in September 2023 with a diagnosis of diabetes, reported the missing money to the facility's administrator, who confirmed the report with a family member. However, the investigation was incomplete as it lacked interviews with staff members who had contact with the resident during the relevant period, and the resident was not offered a search of her room and belongings. Interviews with various staff members revealed a lack of communication and follow-up on the resident's report. A CNA recalled hearing about the missing money but did not engage further, while an LPN reported the issue to social services, who claimed it had been addressed. The administrator admitted to not interviewing additional staff and acknowledged the investigation should have been more thorough. The facility's policy required comprehensive investigation steps, which were not followed, leading to the deficiency.
Inaccurate MDS Assessments for Cognitive and Mood Status
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for two residents, leading to an inaccurate representation of their cognitive and mood status. Resident 23, admitted in 2021 with heart failure, had significant change and quarterly MDS assessments that did not include evaluations of cognitive status or depression screening. Despite being alert and oriented, these assessments were marked as not assessed. Staff responsible for completing these sections confirmed the oversight, acknowledging that the resident's cognitive and mood status were not evaluated as required. Resident 16, admitted in January 2023 with vascular dementia, was inaccurately documented as being in a persistent vegetative state in the annual MDS. However, observations and staff interviews revealed that the resident could respond verbally to questions, albeit quietly. The nurse practitioner, who documented the vegetative state, was unaware of the resident's verbal abilities, which were confirmed by other staff members. This discrepancy highlighted a failure in communication and assessment accuracy, resulting in incorrect MDS coding for the resident.
Failure to Complete PASARR Level II Screening for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure a PASARR Level II screening was completed for a resident with a serious mental illness. The resident was admitted in October 2023 with a diagnosis of delusional disorders, which required further mental health screening as indicated by the PASRR Level 1 form completed on October 19, 2023. However, there was no evidence in the resident's clinical record that a referral for further screening was made. Staff 5, from Social Services, was unaware of the need for a referral and acknowledged that reviewing PASRR Level 1 forms during regular care conferences was not a standard practice. Staff 2, the Director of Nursing Services, stated that she expected referrals for further evaluation to be completed within a week once deemed appropriate, but this was not done for the resident in question.
Failure to Implement Resident-Centered Care Plan for Bed Mobility
Penalty
Summary
The facility failed to implement a resident-centered care plan for a resident who required assistance from two staff members for bed mobility. The resident, who was admitted with hepatic encephalopathy and a spinal fracture, was cognitively intact and had a care plan indicating the need for two staff members to assist with repositioning. However, an agency CNA attempted to reposition the resident alone, instructing the resident to grab the headboard and pull themselves up in bed, which was against the care plan's directive. The incident was confirmed by the Director of Nursing Services, who noted that the CNA did not follow the care plan requiring two staff members to be present. The CNA admitted to repositioning the resident without assistance, despite being aware of the care plan requirements. This action led to the resident expressing a preference not to have the CNA in their room again, highlighting a failure to adhere to the established care plan and potentially compromising the resident's safety and comfort.
Failure to Provide Individualized Activity Programs
Penalty
Summary
The facility failed to provide an ongoing program to support individual activity interests and preferences for two residents, leading to a deficiency in their care. Resident 27, who was admitted with diagnoses including a stroke and disease of the pharynx, was nonverbal and dependent on staff for activities. Despite having a care plan that included preferences for music, television, and social interactions, Resident 27 was observed in bed without these activities being provided. The Activity Director admitted to not providing the necessary one-to-one visits or sensory activities as outlined in the care plan, and the resident's participation in group activities was limited by staff availability. Similarly, Resident 16, diagnosed with vascular dementia, was also found to be lacking in activity engagement. The resident's care plan included preferences for music, television, and group activities, but observations revealed that these were not consistently provided. The Activity Director acknowledged that one-to-one visits were insufficient and that the resident's participation in group activities was dependent on staff availability rather than the resident's preferences. Family members and staff noted discrepancies in the resident's activity preferences, indicating a lack of communication and understanding of the resident's needs. Both residents were at risk of decreased quality of life and social isolation due to the facility's failure to adhere to their care plans and provide appropriate activities. The Administrator confirmed the lack of activity participation and acknowledged the need for more opportunities for sensory stimulation and social interactions for these residents. The deficiency highlights the facility's inability to meet the individual activity needs of its residents, as evidenced by the observations and staff interviews.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with PTSD, as required by professional standards of practice. The resident, who had a history of trauma including a physical assault and a sudden violent death, did not have individualized interventions or identified triggers documented in their care plan or health record. Despite being cognitively intact and able to articulate their triggers, such as feeling trapped, closed bedroom doors, and groups of people, the facility did not assess or document these triggers to mitigate potential re-traumatization. Staff interviews revealed a lack of awareness and documentation regarding the resident's specific triggers. The social services staff member admitted to not having asked the resident about their triggers and relied on the psychologist for assistance with PTSD triggers. The resident's care plan lacked specific interventions to address their trauma, and staff were not informed of the resident's triggers, which led to the resident experiencing distress during activities involving crowds. The facility administrator acknowledged the expectation for identified triggers and interventions to be in place, which were absent in this case.
Failure to Provide Dental Services for Residents
Penalty
Summary
The facility failed to obtain necessary dental services for two residents, leading to unmet dental needs. Resident 16, admitted with vascular dementia, was noted to have oral health issues, including likely cavities or broken teeth, as per their Annual MDS. Despite a care plan indicating the need for dental care and a family member's request for dental services, no referral was made. Staff members, including the Social Services representative responsible for scheduling dental appointments, were unaware of the need for a referral, and the resident had not been seen by a dentist. Similarly, Resident 22, admitted with diabetes, was identified as having dental issues requiring attention. The resident expressed a desire to see a dentist, but no action was taken to facilitate this. The resident's Annual MDS and care plan both indicated the need for dental services, yet the Social Services staff did not follow up on these needs. The resident had not been seen by a dentist since the previous year, and staff were unaware of the current need for a dental referral.
Failure to Maintain Bed Rail Safety
Penalty
Summary
The facility failed to ensure the proper inspection and maintenance of a bed rail for a resident, which placed the resident at risk for potential injury. The resident, who was admitted with a history of falls and unsteadiness, had bilateral mobility bars on their bed to assist with mobility and transfers. The resident reported that the right mobility bar was loose and had been in need of repair for months, but despite informing several staff members, no action was taken. Observations by the state surveyor confirmed that the mobility bar was extremely loose, turning almost 180 degrees from side-to-side. The Maintenance Director, upon inspection, acknowledged that the mobility bar was broken and stated that it had not been reported to him for repair. The LPN/RCM confirmed that the resident used the mobility bars for bed mobility, while the DNS stated that she expected the mobility bars to be securely and properly installed. The facility's policy required devices and equipment to be maintained according to the manufacturer's instructions, but this was not adhered to in this case, leading to the deficiency.
Failure to Provide Grooming Assistance to Resident
Penalty
Summary
The facility failed to provide adequate personal grooming assistance to a resident who was unable to perform activities of daily living (ADLs) independently. The resident, admitted in January 2023 with vascular dementia, was in a persistent vegetative state and required full assistance for all ADLs, including shaving. A physician's order from January 2025 indicated the use of a hair removal cream for facial hair, but observations on February 24, 2025, revealed the resident had significant facial hair growth. A family member expressed disappointment, noting the resident's preference for hair removal cream due to past issues with razor sores. Interviews with staff revealed a lack of action in applying the hair removal cream. A CNA stated that nurses were responsible for applying the cream but had not seen it used. An LPN admitted to being responsible for the application but had not done so due to nervousness. The Director of Nursing Services acknowledged the resident's need for grooming. This inaction resulted in the resident not receiving the necessary grooming care as per the care plan and physician's order.
Improper Sanitation of Garbage Area
Penalty
Summary
The facility failed to maintain proper sanitation in the garbage area, as observed on two separate occasions. One of the two lids on a dumpster was left open during both observations, and nine medical gloves were found scattered under and outside the bin. Additionally, a trash bag was left untied, emitting an odor and containing used medical supplies such as chucks (bed pads), used briefs, N95 masks, surgical masks, and gloves. This was confirmed by Staff 2 (DNS) on the second day of observation, indicating improper maintenance of the garbage area.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse, as evidenced by an incident involving two residents. Resident 4, who was admitted with a diagnosis of alcohol abuse with alcohol-induced psychotic disorder, verbally abused Resident 5, who was admitted with chronic respiratory failure. The incident occurred near the nurses' station when Resident 4 yelled and swore at staff and Resident 5, using offensive language. Resident 5 reported feeling verbally abused and unsafe unless Resident 4 was confined to their room. Staff 6, a CNA, confirmed witnessing Resident 4's verbally aggressive behavior towards both residents and staff, noting frequent use of offensive language. Staff 2, the DNS, acknowledged the incident after reviewing video footage and stated that Resident 4 continued to be abusive and was not appropriate for the facility.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to provide bathing assistance to a resident who required partial assistance with showers. The resident, admitted in December 2020 with a diagnosis of congestive heart failure, was not provided assistance with showers as scheduled on July 1 and July 3, 2023. This resulted in the resident not receiving the necessary bathing assistance for a week. The resident confirmed not being offered showers on these dates, and a staff member, an LPN/Resident Care Manager, verified that the records indicated showers were not provided or attempted on the specified dates.
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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