Cascade Terrace Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Portland, Oregon.
- Location
- 5601 Se 122nd Avenue, Portland, Oregon 97236
- CMS Provider Number
- 385187
- Inspections on file
- 25
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Cascade Terrace Post Acute during CMS and state inspections, most recent first.
Two residents with psychosocial risk factors reported that an RN made repeated undignified and unprofessional comments during intimate care, including telling them not to fart on him during peri and catheter care. Both residents described feeling uncomfortable, awkward, and disrespected. The RN acknowledged routinely using a phrase about not falling or farting on him with all residents as a supposed rapport-building joke, and another staff member confirmed hearing this comment during care. Facility leadership acknowledged that these comments did not honor resident dignity.
The facility failed to timely report an allegation of physical abuse to the State Agency after a resident with cognitive impairment was documented as placing a pillow over another resident’s face and throwing heat packs at the resident while sleeping. Nursing staff reported the incident to the Administrator, who decided it would be investigated internally but not reported externally, and other RNs confirmed that administration determined the event was not reportable. The Administrator acknowledged awareness that all abuse allegations must be reported within two hours but did not do so, resulting in a deficiency for failure to report suspected abuse.
A cognitively intact resident with type 2 DM and depression had a documented care plan specifying a preference for female caregivers to be present during care, including routine and skin assessments, to ensure comfort. Despite this, a male RN performed a skin assessment without a female caregiver in the room. An LPN and a CNA confirmed that the resident’s care plan and facility protocol required at least one female caregiver to be present during such assessments, and the administrator acknowledged that the RN failed to honor the resident’s stated needs and preferences.
A resident with obesity and diabetes did not receive prescribed weekly semaglutide injections on several occasions due to issues such as the medication not being filled, confusion about storage requirements, and unclear documentation. LPNs and the DNS confirmed the missed doses, with some staff unaware of proper medication storage procedures.
A resident with brain cancer received temozolomide chemotherapy for 23 days instead of the prescribed 5-day cycle due to a failure in order verification and documentation. This error led to severe blood cell deficiencies and required multiple transfusions and hospitalizations.
The facility did not ensure adequate supervision or hazard prevention for two residents—one with a history of substance use disorder who experienced fatal and non-fatal overdoses without appropriate care planning or staff training, and another with hemiplegia who was involved in a transfer-related fall without subsequent education or intervention for safe transfers.
The facility did not submit mandatory direct care staffing information for a fiscal quarter as required by policy, with both payroll/human resources staff and the administrator unaware of the omission and indicating that the corporate office was responsible for the submission.
The facility did not provide required training on its Quality Assurance and Performance Improvement (QAPI) program to staff. Multiple staff members, including CNAs and an LPN, reported they were unaware of the QAPI program and had not received any related training. Review of training records confirmed the absence of QAPI training for all staff.
The facility did not provide RN coverage for eight consecutive hours on four separate Saturdays, as required. Staff acknowledged the lack of RN coverage and noted challenges in staffing on weekends, while the administrator was unaware of these lapses.
The facility did not accurately post daily nurse staffing information, with errors including misclassification of staff roles and missing entries for Nursing Assistants on several days. Staff were incorrectly listed or omitted from the Direct Care Staff Daily Report, and administrative staff were unaware of these inaccuracies.
Surveyors found that medication carts containing prescription and over-the-counter drugs, including antibiotics and insulin, were left unlocked and unattended in hallways with staff and residents nearby. Additionally, expired medications and an opened vial of Tubersol without a documented open date were found in the medication storage room. Staff acknowledged these lapses in medication security and storage practices.
A resident with diabetes and an amputation, who was cognitively intact, did not receive requested double portions and a hamburger despite repeated requests and an order card specifying these preferences. Staff confirmed the resident's ongoing requests and noted inadequate systems for meeting food and cultural preferences.
Surveyors found that food items in unit refrigerators were not labeled or dated after opening, and personal employee beverages were stored alongside resident items. Additionally, the facility's only ice machine was not plumbed with an air gap, creating a risk of contamination for ice used in resident beverages. Staff acknowledged these practices did not meet facility expectations.
A resident with dementia and no documented cognitive impairment was found with Aspercreme lidocaine gel at the bedside, which the resident used independently. Staff confirmed that medications should not be kept at the bedside and that no assessment had been completed to determine the resident's ability to self-administer the medication.
Staff failed to maintain the privacy of resident health information by leaving an unlocked computer screen displaying sensitive data unattended and by leaving confidential paper records exposed on the nurses station counter. These actions resulted in multiple residents' personal and medical information being accessible to unauthorized individuals, with staff and administration acknowledging that such information should have been secured.
The facility did not complete comprehensive admission assessments within 14 days for three residents with complex medical conditions, including diabetes, chronic kidney disease, stroke, and amputation. Required MDS documentation and Care Area Assessments were incomplete or unsigned, and staff confirmed the assessments were overdue, resulting in a lack of timely information for individualized care planning.
Two residents had inaccurate MDS assessments: one was not coded as edentulous despite lacking natural teeth, and another was coded as having adequate hearing despite documented and observed hearing impairment. Staff confirmed the inaccuracies in both cases.
A resident with dementia and urinary retention, dependent on staff for bathing, did not receive scheduled showers as outlined in their care plan. Documentation and staff interviews confirmed that the resident did not refuse showers, yet bathing logs showed inconsistent provision of showers and a lack of documentation for missed or refused showers.
Two residents did not receive individualized activities in accordance with their documented preferences and care plans. Both were frequently left in their rooms without access to music, reading materials, or other preferred activities, and staff did not offer or facilitate these options, despite facility policy and care plan requirements.
Three residents did not receive care as ordered, including failure to obtain a custom AFO for a resident with hemiplegia, lack of assessment and treatment for a resident's pre-existing facial skin condition, and failure to administer PRN hydralazine for another resident with hypertension despite elevated blood pressure readings. Staff interviews confirmed that required actions were not taken in each case.
A resident with end-stage renal disease and severe cognitive impairment did not consistently receive required pre- and post-dialysis assessments or proper communication between the facility and the dialysis center. Documentation was missing for multiple dialysis sessions, and staff interviews confirmed that licensed nurses did not always complete necessary forms or assessments as outlined in facility policy.
A resident receiving Clopidogrel for clot prevention was not monitored for adverse side effects, despite developing multiple unexplained bruises. Staff interviews and record reviews confirmed that there was no documentation or orders for monitoring anticoagulant side effects, and expected shift documentation was not completed.
A resident with a stroke and cerebral edema, requiring extensive assistance, did not receive scheduled baths or showers as per their care plan. Despite being nonverbal and unable to refuse care, the resident's family noted the lack of bathing, and staff confirmed that showers were not completed due to low staffing levels. The facility's administration was informed but did not provide further information.
A resident with a PEG tube for nutrition was not administered tube feedings according to physician orders, with frequent delays documented. Staff confirmed that feedings should occur within an hour of scheduled times, but this was not consistently followed, risking insufficient nutrition.
Undignified Comments by RN During Intimate Care to Two Residents
Penalty
Summary
The deficiency involves staff failure to honor residents’ rights to be treated with respect and dignity during personal care. Resident 1, admitted with type 2 diabetes and depression, had a care plan dated 7/25/25 identifying risk for decreased psychosocial well-being and adjustment issues, with directions for staff to use appropriate and effective communication, encourage personal preferences, and honor quality-of-life choices to ensure dignity and respect. During a routine skin assessment on 2/6/26, Resident 1 reported that a registered nurse (Staff 6) stated, “don’t fart on me, a lot of people fart on me,” while examining the resident’s peri-area and areas near the anus. Resident 1 reported feeling disrespected, uncomfortable, and undignified, and stated the comment was unnecessary and did not want Staff 6 to provide care in the future. A CNA (Staff 7) corroborated hearing Staff 6 tell Resident 1 not to fart in his/her face during the skin assessment. Resident 5, admitted with cellulitis and agoraphobia, had a care plan dated 1/23/26 identifying risk to psychosocial well-being, including increased agitation and tearfulness, and directing staff to honor the resident’s preferences and choices to promote dignity and decrease anxiety. Resident 5 reported that the same RN (Staff 6) made unprofessional comments and “weird jokes” during care, including asking the resident not to fart on him while performing routine catheter care, which made the resident feel awkward and uncomfortable. In an interview, Staff 6 confirmed using the statement, “I am the registered nurse today. I have a couple of rules, don’t fall on me, don’t fart on me,” with all residents during care, explaining he believed it was humorous and a way to establish rapport. The Administrator (Staff 1) stated that Staff 6’s behavior and comments, including the phrase “don’t fart on me,” did not honor resident dignity and were inappropriate when providing resident care.
Failure to Timely Report Allegation of Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse to the State Agency within the required two hours after an incident involving two residents. Resident 9, who was admitted in 10/2024 with metabolic encephalopathy and atrial fibrillation and had a care plan dated 11/4/24 identifying cognitive loss affecting decision-making ability, was documented in a 2/7/26 facility incident report (completed on 2/15/26) as having placed a pillow over another resident’s face and thrown heat packs at that resident while the resident was sleeping. Staff interviews revealed that a RN case manager reported the incident to the Administrator, who stated the incident would be investigated but not reported to the State Agency, and the RN case manager believed administration handled the investigation. Another RN stated she reported the incident based on information from care staff, and that administration determined it was not reportable to the State Agency. The Administrator stated he was notified of the incident by care staff and did not report it to the State Agency because he did not believe it to be abuse, while acknowledging that all allegations of abuse must be reported to the State Agency within two hours of the allegation. This sequence of events, including the documented allegation of potentially abusive behavior by one resident toward another and the Administrator’s decision not to report the allegation despite staff notification and his awareness of reporting requirements, led to the deficiency for failure to timely report suspected abuse to the proper authorities.
Failure to Honor Resident’s Care Plan for Female Caregiver Preference During Nursing Assessment
Penalty
Summary
The deficiency involves the facility’s failure to implement a resident’s care plan regarding caregiver gender preference during the provision of nursing care. The resident, admitted in July 2025 with diagnoses including type 2 diabetes and depression, had a 7/7/25 cognitive assessment showing a BIMS score of 15/15, indicating no cognitive impairment. The resident’s 7/25/25 care plan documented an individualized preference for female caregivers to promote comfort during care, and directed staff to ensure female caregivers were available when providing care. During a routine skin assessment on 2/17/26 at 10:19 AM, the resident reported that Staff 6 (RN), a male nurse, conducted the assessment without an additional female caregiver present in the room, contrary to the resident’s stated preference and the care plan directives. Interviews with staff confirmed awareness of the resident’s care plan and the expectation to honor the resident’s preference. On 2/17/26 at 11:07 AM, Staff 5 (LPN) stated that standard protocol based on the resident’s care plan was to ensure at least one female caregiver was present during routine assessments, including skin assessments, and acknowledged that staff were expected to honor this preference. At 11:15 AM, Staff 6 (RN) acknowledged providing care to the resident but refused to answer whether a female caregiver was present. At 12:04 PM, Staff 8 (CNA) stated that the resident’s preference was for female caregivers only and reported that Staff 6 provided nursing services without a female caregiver in the room. At 3:26 PM, Staff 1 (Administrator) stated that Staff 6 failed to honor the resident’s needs and preferences by performing nursing services without ensuring female caregivers were present.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to ensure that physician orders for semaglutide (Ozempic) injections were followed for a resident with obesity and diabetes. The resident was admitted in 2025 and had a physician order dated 9/23/25 for weekly semaglutide injections. However, medication administration records and treatment administration records for October, November, and December 2025 showed that the resident did not receive the medication on multiple scheduled dates. Progress notes indicated that the medication was not administered due to reasons such as the prescription not being filled, a new order being needed, the prescription having ended, or the resident requesting a prescription, with some notes left blank. Staff interviews confirmed that the medication was not given as ordered, with one LPN stating she did not administer the medication because she believed it needed refrigeration and was unaware it was kept in the medication cart once opened. The Director of Nursing Services acknowledged the missed doses.
Chemotherapy Medication Administered in Excess of Prescribed Duration
Penalty
Summary
The facility failed to ensure that chemotherapy medications were administered as ordered for a resident with a diagnosis of Glioblastoma. The resident was supposed to receive temozolomide, a chemotherapy drug, for five days as part of a 28-day maintenance cycle, in accordance with standard dosing schedules and the prescriber's intent. However, due to a lack of clear documentation and order verification, the medication was administered daily for 23 consecutive days, far exceeding the prescribed duration. The error originated when a nurse transcribed the temozolomide order into the resident's clinical record without confirming the exact duration of administration, despite having a conversation with the neuro-oncology clinic. The nurse could not recall the specific instructions regarding the number of days the medication was to be given and relied on a paper order that was never located during the subsequent investigation. The Director of Nursing did not verify the entry or the existence of a valid paper order, and the medication was administered according to the incorrect transcription. The facility's policy required clarification of ambiguous orders and documentation of such clarifications, but this process was not followed. As a result of the prolonged administration of temozolomide, the resident developed severe complications, including thrombocytopenia, pancytopenia, and neutropenia, which necessitated multiple blood transfusions, emergency department visits, and hospitalizations. Interviews with facility staff and the resident's medical providers confirmed that the medication was given for a much longer period than intended, directly leading to these adverse outcomes.
Failure to Prevent Hazards and Provide Adequate Supervision for Residents with SUD and Mobility Risks
Penalty
Summary
The facility failed to keep residents free from hazards and provide adequate supervision, particularly for residents with a known history of substance use disorder (SUD) and those at risk for accidents during transfers. One resident with a history of polysubstance use was admitted and later experienced two critical incidents: first, being found unresponsive in the facility's parking lot due to a suspected opioid overdose, and second, being found deceased in their bathroom with drug paraphernalia present. Despite these events, there was no evidence that the resident's care plan addressed their history of substance use, nor was there any indication that monitoring for opioid use was initiated after the resident returned from the hospital following the first overdose. Staff interviews revealed a lack of knowledge and training regarding SUD. Multiple staff members, including CNAs, LPNs, and housekeepers, reported not receiving education on identifying signs and symptoms of drug use, monitoring residents with SUD, or handling drug paraphernalia. The Social Services Director confirmed that training on SUD was only provided to licensed nursing staff and not to CNAs or other direct care staff. Additionally, the facility did not update care plans or implement monitoring for other residents with a history of SUD, as identified by the Social Services Director. In another case, a resident with hemiplegia and severe cognitive impairment required extensive assistance for car transfers and had a witnessed fall during a transfer with a family member. Although a physical therapy referral was made, neither the resident nor the family member received education or training on safe car transfers following the incident. Staff were unaware that the resident continued to go out with the family member after the fall, and no further interventions were implemented to address the risk of future accidents.
Removal Plan
- Review all residents' records to identify other residents with history of or active substance use disorder.
- Identify residents with active, suspected, or history of substance use and list them in a binder at the nursing stations. Place a sticker on the residents' name plates outside their rooms to alert staff of potential hazards associated with active substance use disorder.
- Offer substance use treatment services to residents identified with history of or active substance use disorder.
- Assess residents identified with history of or active substance use disorder upon return from independent offsite outing for suspected substance use.
- Generate an incident report and notify law enforcement if required for residents assessed upon return from independent offsite outing or identified as active substance use.
- Educate staff, including temporary or agency staff, on the location of the binder with residents identified with suspected or history of substance use disorder.
- In-service staff, including temporary or agency staff, on substance use disorder, signs of abuse related to drug use, actions to take if active use is suspected, reporting suspected drug paraphernalia, and facility policy on resident possession and use of illegal substances.
- Place residents identified with drug paraphernalia or signs/symptoms of active drug use on alert monitoring, notify MD, place POC task to alert CNA for increased monitoring for drug paraphernalia, notify law enforcement if required, generate an incident report, and complete resident assessment.
Failure to Submit Required Payroll-Based Staffing Data
Penalty
Summary
The facility failed to submit the required direct care staffing information for fiscal year 2024, quarter four, as mandated by their Reporting Direct Care Staffing Information (Payroll-Based Journal) policy. The policy requires that complete and accurate staffing data, based on payroll and other verifiable and auditable sources, be electronically reported to CMS for each fiscal quarter within 45 days after the quarter ends. Review of records showed that the data for the specified quarter was not submitted. During interviews, the staff member responsible for payroll and human resources was unaware of the missing submission and indicated that the corporate office was responsible for this task. The facility administrator was also unaware that the data had not been submitted.
Failure to Provide QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training to staff on the elements and goals of its Quality Assurance and Performance Improvement (QAPI) program. During interviews, multiple staff members, including certified nursing assistants and an LPN, reported being unaware of the QAPI program and confirmed they had not received any related training. A review of the facility's list of new hire and annual trainings by the Payroll/Human Resources staff and the administrator confirmed that QAPI training was not included. This deficiency was identified for the entire facility, as no staff had received the required QAPI training.
Failure to Ensure Required RN Coverage on Multiple Days
Penalty
Summary
The facility failed to provide registered nurse (RN) coverage for eight consecutive hours on four separate Saturdays within a 33-day review period, as evidenced by the Direct Care Staff Daily Reports (DCSDR). Specifically, there was no RN coverage for the required duration on 7/20/24, 8/3/24, 3/22/25, and 4/12/25. Staff responsible for payroll and human resources acknowledged the lack of RN coverage on these dates and cited difficulty in finding RN coverage on weekends. The facility administrator was not aware of the absence of RN coverage on the identified days. No information was provided regarding specific residents affected, their medical history, or their condition at the time of the deficiency.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate and complete nurse staffing information for 14 out of 34 days reviewed. Review of the Direct Care Staff Daily Report (DCSDR) revealed incorrect information on multiple dates, including the entry of a 'Sitter' with hours worked as part of the staff count, and the absence of entries for Nursing Assistants on certain shifts. On one occasion, a staff member was observed wearing a CNA badge but confirmed he was not a CNA, and was not listed correctly on the DCSDR. Payroll/Human Resources staff acknowledged that the Sitter was a CNA assigned to one-on-one duties and should have been included in the CNA count, but the DCSDR did not accurately reflect this information. Further interviews confirmed that the same staff member worked with residents on several dates and should have been counted as a Nursing Assistant, but was not. The Administrator was unaware of the incorrect information on the DCSDR. These inaccuracies resulted in incomplete and inaccurate staffing information being posted for residents and the public.
Unsecured Medication Storage and Expired Medications Identified
Penalty
Summary
Surveyors observed multiple instances where medication carts were left unlocked and unattended in hallways, with both staff and residents passing by. On several occasions, medication carts containing prescription medications, over-the-counter drugs, antibiotics such as ceftriaxone, and insulin were found unlocked near resident rooms. Staff members, including a CMA and RNs, were noted to leave the carts unattended and unlocked, despite the expectation that medication carts should be locked when not in use. These observations were confirmed through interviews with staff, who acknowledged the expectation for secure storage. Additionally, the medication storage room was found to contain expired medications, including Vitamin A, Complete Women 50+ multi-vitamin with minerals, and L-Argine. A vial of Tubersol, used for tuberculosis testing, was also found opened without a documented open date, despite the requirement that it is only good for 30 days after opening. Staff confirmed the presence of expired medications and the lack of an open date on the Tubersol vial.
Failure to Meet Resident Dietary Preferences and Portion Requests
Penalty
Summary
A resident with diabetes and a below-the-knee amputation, who was cognitively intact, reported not receiving enough food and specifically requested larger portions. Despite having an order card for double portions and a hamburger on the side, the resident was observed receiving small portions and no hamburger. Staff interviews confirmed that the resident had requested double portions and a hamburger regularly, and that there was not a good system in place to meet resident preferences and cultural preferences for food. The dining manager and dietary staff acknowledged the resident's requests, but the upgrade to double portions was not implemented until after the deficiency was observed.
Improper Food Storage and Ice Machine Plumbing Deficiencies
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling and storage of food items in refrigerators located behind two nurses stations. Specifically, multiple food items, including covered plastic ramekins of peanut butter, a coffee mug with clear liquid and ice, and containers of nutritional shakes, were found opened, unlabeled, and undated. Staff members acknowledged these items should have been labeled with the date they were opened to ensure proper tracking and timely disposal. Additionally, an employee's personal beverage was found stored in one of the unit refrigerators, contrary to facility expectations. Further, the facility's only ice machine was found to be improperly plumbed, with its drain pipe lacking an air gap and discharging directly through a wall to the outside garden area. This setup did not prevent potential backflow of contaminated matter into the ice machine. The Dietary Manager confirmed the ice from this machine was used for preparing residents' beverages, and the Administrator acknowledged the risk of contamination due to the current drainage system.
Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
A resident admitted with dementia and no cognitive impairment documented on the most recent MDS was found to have Aspercreme lidocaine gel, a topical pain reliever, at their bedside within reach. The resident reported using the gel on their heels. Review of the health record showed that no assessment had been completed to determine the resident's ability to safely self-administer this medication. Multiple staff members, including CNAs and an LPN, confirmed the presence of the medication at the bedside and stated that medications should not be kept in resident rooms, but rather in medication carts. The regional clinical support staff also confirmed that no self-administration assessment had been performed and that the medication should not have been left in the resident's room.
Failure to Protect Resident Health Information Privacy
Penalty
Summary
Facility staff failed to maintain the privacy and confidentiality of resident records for three residents. In one instance, an unlocked computer screen on a treatment cart in a hallway displayed a resident's photo, name, gender, date of birth, age, allergies, code status, attending physician, vital signs, and scheduled treatments. The responsible LPN acknowledged forgetting to lock the computer screen, and the administrator confirmed that screens are expected to be locked when unattended to protect resident information. Additionally, four sheets of resident records containing private information, such as room numbers, names, and details about care (including ostomy bag changes, brief changes, and catheter care), were left unattended on the counter at the central nurses station. Staff were observed leaving these records unsupervised while going in and out of resident rooms, and other residents were seen passing by the exposed information. The LPN on duty confirmed the records were left out from the previous shift and acknowledged that confidential information should not be left in the open. The administrator stated that private information should be under staff supervision or covered.
Failure to Complete Timely Comprehensive Admission Assessments
Penalty
Summary
The facility failed to complete comprehensive admission assessments within the required 14-day timeframe for three residents. For one resident with type 2 diabetes mellitus and chronic kidney disease, the Admission MDS was found incomplete 17 days after admission, lacking provider signatures in key sections and missing completed Care Area Assessments (CAAs) for multiple triggered care areas, including functional abilities, urinary incontinence, nutritional status, pressure ulcers, and pain. Another resident with a history of stroke and type 2 diabetes had an Admission MDS that was still in progress and overdue by five days, as confirmed by facility staff. A third resident, admitted with type 2 diabetes mellitus and a below-the-knee amputation, also had an incomplete Admission MDS 18 days after admission, with unsigned and incomplete CAAs for several triggered care areas such as cognitive status, mood, nutritional status, pressure ulcers, and pain. Staff interviews confirmed that the facility had overdue admission assessments for these residents. The lack of timely and complete comprehensive assessments placed the residents at risk for unmet care needs, as the necessary information to guide individualized care planning was not available within the required timeframe.
Inaccurate MDS Coding for Dental and Hearing Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments were coded accurately for two residents in the areas of dental status and hearing. For one resident with a history of traumatic brain injury, the dental treatment record indicated the resident was fully edentulous, yet the annual MDS did not reflect this status. Direct observation confirmed the absence of natural teeth, and facility staff acknowledged the inaccuracy in the MDS coding for this resident. For another resident admitted with heart failure, the nursing admission evaluation documented poor hearing in both ears. However, the admission MDS indicated the resident's hearing was adequate. Observations showed that the resident could only hear when spoken to at close range and with increased volume, and the resident reported being unable to hear and needing hearing aids. Multiple staff members confirmed the need to speak loudly and closely for the resident to hear, and facility staff acknowledged the MDS was inaccurately coded regarding the resident's hearing status.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
The facility failed to ensure that a dependent resident received showers as scheduled, resulting in a deficiency related to activities of daily living (ADLs). The resident, who was admitted with dementia and had a catheter due to urine retention and bowel incontinence, was care planned to receive bathing or showering twice weekly or per preference. Documentation showed that the resident was dependent on staff for bathing and did not refuse showers. However, bathing logs indicated that the resident did not consistently receive showers according to the scheduled days, with significant gaps between shower dates. Interviews with the resident and multiple staff members confirmed that the resident did not refuse showers and expected to receive them at least twice a week. Staff acknowledged that missed showers should be made up the next day and refusals should be documented, but there was no evidence in the progress notes that additional showering opportunities were provided when showers were missed or refused. The regional clinical support staff confirmed that the resident did not receive showers as scheduled and that missed or refused showers should have been documented.
Failure to Provide Person-Centered Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing, person-centered activity program for two of three sampled residents, resulting in unmet psychosocial and quality of life needs. For one resident with dementia, assessments and care plans indicated preferences for activities such as reading, listening to music, spending time outdoors, and participating in religious services. Despite these documented preferences, the resident was frequently observed alone in their room, either in bed or in a wheelchair, often yelling for help. There were no books, newspapers, magazines, music, or TV available in the room, and the resident was not observed participating in group or one-to-one activities. Staff interviews confirmed the absence of activity materials and a lack of engagement with the resident's stated interests, with staff unaware of or not providing the preferred activities. Another resident, admitted with necrotizing fasciitis, had an activity assessment and care plan indicating the importance of listening to music, keeping up with the news, and having reading materials. Observations revealed that this resident was also left in their room without music, TV, or other activity materials, and staff did not offer to assist with turning on the TV or music. The resident expressed not knowing what activities were available and indicated interest in listening to music, podcasts, or audiobooks, but these were not provided. Staff interviews further revealed a lack of awareness of the resident's preferences and a failure to offer or facilitate the use of available activity resources. The facility's own policy required activities to be based on comprehensive, resident-centered assessments and to reflect individual preferences, with documentation in the medical record. However, both direct observation and staff interviews demonstrated that these requirements were not met for the two residents, as their preferences were not honored and activity materials were not provided or facilitated, despite being documented in their care plans and assessments.
Failure to Provide Ordered Treatments, Skin Assessments, and PRN Medication Administration
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and resident needs for three residents. One resident with hemiplegia was determined to require a custom Ankle Foot Orthosis (AFO) for stabilization and assistance with activities of daily living. Despite multiple clinical notes and evaluations indicating the need for a custom AFO, there was no evidence that the facility obtained the device. Staff interviews confirmed that no action had been taken to secure the orthosis, and the resident and family member both reported that the brace had not been received or used as ordered. Another resident was admitted with spastic hemiplegia and was found to have red blotches and bumps on both cheeks, which were present prior to admission and caused irritation. The facility's policy required identification, assessment, and documentation of skin impairments, as well as notification of the physician and obtaining treatment orders if needed. However, the skin condition was not assessed or documented by nursing staff, and no treatment was initiated. Staff interviews revealed that the skin issue was not reported or evaluated, and the required procedures for new skin impairments were not followed. A third resident with hypertension had a physician order for as-needed hydralazine to be administered for blood pressures greater than 160. Multiple blood pressure readings above this threshold were recorded, but there was no evidence in the medication administration record that the medication was given as ordered. Staff confirmed that the resident should have received the medication when indicated, but this did not occur.
Failure to Ensure Proper Dialysis Care and Communication
Penalty
Summary
The facility failed to ensure proper dialysis care and communication for a resident with end-stage renal disease and severe cognitive impairment. According to the facility's policy, licensed nurses were required to complete pre-dialysis and post-dialysis communication forms, monitor the resident before and after dialysis, and ensure communication with the dialysis center. Record review showed that for multiple dialysis sessions, there was missing documentation, including absent pre-dialysis, post-dialysis, and dialysis center communication forms. There was also no evidence that nursing staff contacted the dialysis center to obtain reports for several treatment dates. Interviews with staff confirmed that the required forms were not consistently completed and that assessments by licensed nurses were sometimes missed upon the resident's return from dialysis. A private caregiver reported that only CNAs typically took vital signs after dialysis, and licensed nurses did not perform assessments as required. Staff acknowledged the importance of the communication forms and assessments, and confirmed the gaps in documentation and communication for the identified dates.
Failure to Monitor for Adverse Effects of Anticoagulant Medication
Penalty
Summary
A resident with a diagnosis of peripheral vascular disease was admitted to the facility and prescribed Clopidogrel Bisulfate, an anticoagulant, for clot prevention. The April 2025 Medication Administration Record (MAR) indicated the resident was to receive 75mg of the medication daily at bedtime. Despite the known side effects of Clopidogrel, such as collection of blood under the skin and deep, dark purple bruises, there was no evidence in the medical record that adverse side effects were being monitored. During an interview, the resident displayed multiple bruises on both arms and was unaware of their origin. Staff interviews revealed that skin checks were only completed weekly, and no bruising had been documented. Additionally, a new skin tear was noted by staff, but there was no documentation of bruising or monitoring for side effects related to the anticoagulant in the resident's chart. Further review and interviews with nursing staff and clinical leadership confirmed the absence of any orders or documentation for monitoring the resident for adverse effects of anticoagulant therapy. Staff acknowledged that monitoring for side effects should have been conducted and documented each shift, but this was not done. The lack of monitoring and documentation placed the resident at risk for medication complications associated with anticoagulant use.
Failure to Provide ADL Care for Resident
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for a resident who required extensive assistance due to conditions including a stroke and cerebral edema. The resident was admitted in August 2024 and was nonverbal, unable to express understanding, and required total assistance for bathing. The care plan specified that the resident was to be bathed or showered twice a week. However, records from August 2024 indicated that no baths or showers were completed for the resident during that time. Interviews with staff and a complainant revealed that the resident's family members frequently visited and noted the lack of bathing, even washing the resident's hair themselves due to neglect. A CNA confirmed that the resident was scheduled for showers during the evening shift, but these were not carried out. Another former CNA mentioned that staffing levels were low during that period, contributing to the failure to provide the necessary care. The facility's administrator and director of nursing services were informed of these findings but did not provide additional information.
Failure to Administer Tube Feeding as Ordered
Penalty
Summary
The facility failed to administer tube feeding according to physician orders for a resident who was admitted with diagnoses including stroke and cerebral edema. The resident was nonverbal, NPO, and received nutrition via a PEG tube. The physician's orders specified that the resident should receive 290 ml of a standard formula with fiber five times a day at specific times. However, the facility did not adhere to these orders, as the tube feedings were frequently administered late, sometimes by several hours, as documented in the MAR Audit Report. Witnesses, including a complainant and several staff members, confirmed the discrepancies in the administration times. The registered dietitian and other staff members acknowledged that tube feedings should be administered within an hour before or after the scheduled times, but this was not consistently done. The assistant director of nursing and other staff confirmed the audit results, indicating that the tube feedings were not administered within the time frames ordered by the physician, placing the resident at risk for insufficient nutrition.
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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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