Blue Mountain Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Prairie City, Oregon.
- Location
- 112 East Fifth Street, Prairie City, Oregon 97869
- CMS Provider Number
- 38E040
- Inspections on file
- 15
- Latest survey
- October 17, 2025
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Blue Mountain Care Center during CMS and state inspections, most recent first.
A facility failed to maintain a medication error rate below five percent, resulting in a 19 percent error rate. Multiple residents with diabetes were administered insulin without priming the pens as per manufacturer instructions. Additionally, a resident with atrial fibrillation did not receive diltiazem despite meeting the parameters for administration. The involved RNs acknowledged their lack of awareness regarding the priming requirement.
A facility failed to follow professional standards, leading to delayed implementation of physician orders for a resident with post-surgical care needs and untimely skin assessments for another resident with a new wound. The DNS did not implement admission orders for three days, and a wound assessment was delayed by five days due to the absence of the RNCM.
Two residents requiring assistance with ADLs did not receive adequate nail care, as observed by surveyors. One resident with kidney disease and another with dementia had long, untrimmed nails, despite care plans indicating the need for regular nail care. Staff acknowledged the lack of specific documentation for nail care and confirmed the expectation for routine checks and trimming.
A resident readmitted for post-surgical care did not receive prescribed medications due to the facility's failure to implement physician orders. The DNS received the orders but did not implement them before leaving, despite the administrator's request. As a result, the resident missed doses of doxycycline, losartan, and pravastatin for three days.
The facility failed to assess and monitor pressure ulcers for two residents, leading to discrepancies in wound documentation and care. One resident developed a Stage 2 pressure ulcer on the buttock and forearm, while another had a Stage 4 ulcer with inconsistent measurements. The absence of the RNCM responsible for assessments contributed to the oversight.
Two residents did not receive timely doses of prescribed antibiotics due to a breakdown in the medication reordering process. One resident with chronic kidney disease missed multiple doses of Keflex, while another with diabetes experienced a delay in receiving cephalexin. The DNS was unable to verify medication availability, and the facility administrator acknowledged the reordering issue.
The facility failed to timely address pharmacy recommendations for three residents, leading to prolonged unnecessary medication use and unaddressed monitoring for potential heart risks. Despite pharmacy reviews suggesting medication changes and monitoring, physician responses were delayed, and staff acknowledged the lack of timely follow-up.
The facility failed to maintain accurate medical records for two residents with pressure ulcers, resulting in discrepancies in wound measurements. One resident had conflicting measurements recorded by the DNS on the same day, while another resident's measurements varied between a progress note, a Weekly Wound Observation Tool, and handwritten notes by an RN. These inconsistencies could impact the accuracy of resident care.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 19 percent error rate. This was observed through multiple incidents involving the improper administration of insulin to residents. Resident 164, who was admitted with diabetes, was supposed to receive Novolin R insulin, but the administering RN did not prime the insulin pen as required by the manufacturer's instructions. Similarly, Resident 8, also with diabetes, was administered insulin lispro without priming the pen, despite the manufacturer's instructions. Both RNs involved acknowledged their lack of awareness regarding the need to prime the insulin pens. Additionally, Resident 1, with chronic kidney disease and diabetes, was administered Lantus insulin without the pen being primed. The RN involved admitted to not knowing the priming requirement. Another incident involved Resident 3, who was prescribed diltiazem for atrial fibrillation. The RN held the medication despite the resident's blood pressure and heart rate being within the parameters for administration. These errors highlight a significant deficiency in medication administration practices at the facility.
Failure to Implement Physician Orders and Conduct Timely Skin Assessments
Penalty
Summary
The facility failed to ensure professional standards were followed by a Registered Nurse (RN) in the administration of medications and management of pressure ulcers, placing residents at risk for adverse outcomes. Specifically, Resident 164 was readmitted to the facility with post-surgical care needs following a toe amputation. The Director of Nursing Services (DNS), identified as Staff 2, received the resident's admission physician orders but did not implement them before leaving the facility for the day. This resulted in a delay of three days before the orders were implemented, as confirmed by the facility's Administrator, identified as Staff 1. Additionally, the facility failed to conduct timely skin assessments for Resident 8, who was admitted with diagnoses including diabetes and a sacral fracture. A new wound was identified on the resident's left buttock, but Staff 2 did not assess the wound until five days later. Staff 3, the RN Case Manager, was responsible for skin assessments but was on vacation, and it was expected that Staff 2 would complete these assessments in her absence. This lack of timely assessment and intervention for pressure ulcers further highlights the facility's failure to adhere to professional standards of care.
Failure to Provide Adequate Nail Care to Residents
Penalty
Summary
The facility failed to provide adequate nail care to two residents who required assistance with activities of daily living (ADLs). Resident 10, admitted in 2021 with kidney disease, was observed on two occasions with long, curved fingernails. The resident's care plan indicated a need for ADL assistance, but there was no documented evidence of when nail care was provided. Staff 6, a CNA, stated that nail care was supposed to be done on shower days and as needed, but acknowledged there was no specific documentation for when it was completed. The DNS confirmed the expectation for nursing staff to perform nail care, even for non-diabetic residents, and acknowledged the resident's nails needed trimming. Similarly, Resident 11, admitted in 2023 with dementia and moderate cognitive impairment, also required assistance with ADLs. The care plan included interventions to check and trim nails on bath days and as needed, yet there was no documentation of nail care being provided. The resident expressed that their nails were not trimmed often enough and could not recall the last time they were trimmed. Staff 6 confirmed the expectation for routine nail checks and acknowledged the resident's nails were longer than appropriate. The DNS reiterated the expectation for nursing staff to complete nail care and acknowledged the need for trimming.
Failure to Implement Admission Physician Orders
Penalty
Summary
The facility failed to implement physician orders upon admission for a resident who was readmitted with diagnoses including post-surgical care for a toe amputation. The hospital discharge orders specified that the resident was to receive doxycycline, losartan, and pravastatin. However, on the day following admission, the resident missed doses of all three medications. The Medication Administration Record (MAR) and progress notes confirmed the missed doses. A progress note indicated that a registered nurse was unable to resume many medications and documented the medications given. Another progress note revealed that there were no orders in the resident's chart. The Director of Nursing Services (DNS) received the admission physician orders but did not implement them before leaving the facility for the day. The facility administrator had requested the DNS to review and implement the orders prior to the resident's arrival, but the DNS left the building without doing so. Consequently, the admission physician orders were not implemented for three days, resulting in the resident not receiving the prescribed medications.
Failure to Assess and Monitor Pressure Ulcers
Penalty
Summary
The facility failed to properly assess and monitor pressure ulcers for two residents, leading to a deficiency in care. Resident 8 was admitted with conditions including diabetes and a sacral fracture, and initially, no wounds were noted. However, a wound care order was implemented for a wound on the left buttock, which was later identified as a Stage 2 pressure ulcer. There were discrepancies in wound measurements and assessments, with Staff 2 acknowledging a lack of recent wound care training and failing to conduct timely assessments. Additionally, four Stage 2 pressure ulcers were identified on the resident's left forearm, which were not initially documented. Resident 6, who had a Stage 4 pressure ulcer on the sacral region, also experienced a lack of consistent wound assessments. The Weekly Wound Observation Tool was not completed after a certain date, and discrepancies were found in the wound measurements recorded by different staff members. Staff 5, who conducted a dressing change, noted inconsistencies between her handwritten notes and the official records. The absence of the RNCM, who was responsible for skin assessments, contributed to the oversight, as floor nurses were not typically tasked with these assessments.
Failure to Administer Timely Medications
Penalty
Summary
The facility failed to provide timely pharmaceutical services for two residents, resulting in missed doses of prescribed antibiotics. Resident 1, who was admitted in 2018 with chronic kidney disease, had a physician order dated 8/9/24 for Keflex 500 mg three times daily for a urinary tract infection (UTI). However, the medication administration record (MAR) indicated that Resident 1 did not receive the medication on multiple occasions between 8/10/24 and 8/12/24. Staff 2, the Director of Nursing Services (DNS), acknowledged the missed doses and was unable to verify the availability of Keflex in the electronic medication dispensing system, mistakenly believing that medications were automatically refilled by the pharmacy. The facility administrator identified a breakdown in the medication reordering process by nursing staff. Similarly, Resident 7, admitted in 2023 with diabetes, was discharged from the hospital with a UTI and a prescription for cephalexin 500 mg four times daily. The MAR showed that Resident 7 did not receive the first dose until 8/13/24 at 5:00 PM, despite being readmitted to the facility earlier. Staff 2 confirmed the delay in administering the first dose and demonstrated a lack of knowledge in checking medication inventory. The administrator again cited a failure in the medication reordering process as the cause of the delay.
Delayed Response to Pharmacy Recommendations
Penalty
Summary
The facility failed to address pharmacist recommendations in a timely manner for three residents, leading to the risk of unnecessary medication administration. Resident 8, diagnosed with depression, was recommended by the pharmacy to discontinue mirtazapine on July 8, 2024. However, the physician did not agree to this recommendation until August 6, 2024, resulting in the resident continuing to receive the medication for 29 days beyond the recommendation. Staff acknowledged that the expectation was for the physician to address such recommendations within two weeks. Similarly, Resident 6, with an anxiety disorder, had a pharmacy recommendation on June 26, 2024, to change diazepam to lorazepam due to the high risk of adverse reactions in older adults. This recommendation was not signed by the physician until July 31, 2024, 35 days later. Additionally, Resident 12, with heart disease, bipolar disorder, and depression, had a pharmacy recommendation on June 26, 2024, to monitor for heart-related symptoms and conduct an EKG every six months due to the potential risk of QT interval prolongation. Although the physician agreed to these recommendations on July 3, 2024, there was no documented evidence that the recommendations were addressed, as acknowledged by the staff.
Inaccurate Wound Measurements for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to ensure the accuracy of medical records for two residents with pressure ulcers, leading to discrepancies in wound measurements. Resident 8, who was admitted with diagnoses including diabetes and a sacral fracture, had conflicting wound measurements recorded on the same day. A progress note by the Director of Nursing Services (DNS) indicated a Stage 2 pressure ulcer on the left inner gluteal area with specific measurements, while a Weekly Wound Observation Tool completed later by the same staff member showed different measurements and did not specify which wound it referred to. When questioned, the DNS stated that the progress note was the most accurate. Similarly, Resident 6, who was readmitted with a Stage 4 pressure ulcer of the sacral region, also had inconsistent wound measurements recorded. A progress note by a registered nurse (RN) documented one set of measurements, while the Weekly Wound Observation Tool indicated different dimensions. Upon review, the RN acknowledged discrepancies between the progress note, the observation tool, and her handwritten notes, which contained yet another set of measurements. These inconsistencies in documentation could lead to inaccurate assessments and care for the residents.
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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