Cedar Crossings
Inspection history, citations, penalties and survey trends for this long-term care facility in Portland, Oregon.
- Location
- 6003 Se 136th Avenue, Portland, Oregon 97236
- CMS Provider Number
- 385284
- Inspections on file
- 22
- Latest survey
- January 17, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Cedar Crossings during CMS and state inspections, most recent first.
The facility failed to provide a safe and homelike environment, with tripping hazards in the dining room and damaged flooring and walls in resident areas. A resident with a history of stroke experienced discomfort due to cold room temperatures, which staff struggled to regulate. Other residents reported similar temperature issues, highlighting a broader problem within the facility.
The facility failed to enforce smoking policies and conduct timely assessments for three residents, leading to potential hazards. A resident with chronic heart failure kept smoking materials unsecured, contrary to policy. Another resident with kidney disease had delayed assessments and also kept materials unsecured. A third resident with schizoaffective disorder had no initial assessment or care plan, and staff were unclear about the policy. The facility acknowledged these issues, indicating a systemic problem in policy enforcement.
The facility failed to provide adequate nursing staff, resulting in prolonged call light response times for residents with conditions such as morbid obesity, diabetes, and cancer. Staff interviews confirmed that response times were longer during short-staffed periods, and the facility did not meet state minimum CNA and bariatric staffing ratios on several occasions.
The facility did not complete annual performance reviews for five CNAs, as confirmed by the DNS and Administrator. This oversight was identified during an interview and record review, where it was found that the personnel profiles lacked the necessary documentation, potentially compromising resident care.
The facility failed to properly store, label, and dispose of medications, as observed in three out of four medication carts. Expired and improperly labeled medications, including insulin and Naloxone, were found, and a medication cart was left unlocked and unattended. Additionally, Lorazepam tablets for a resident without an order and multiple opened medicated creams without open dates were discovered. Staff was uncertain about labeling requirements, and the DNS expected adherence to the facility's policy.
A resident with severe cognitive impairment and dysphagia was not provided with necessary dental services since admission, despite having broken and decayed teeth. Observations and family reports indicated poor oral hygiene, and staff confirmed the resident was not seen by a dentist. The facility failed to address the resident's dental needs, as confirmed by the DNS.
A resident with deep vein thrombosis, atrial fibrillation, and high blood pressure experienced leg discomfort due to swelling. Despite a provider's order for compression stockings, the resident did not receive them, and they were not observed on the resident. A progress note indicated an order for Tubigrip, but it was not implemented due to an oversight. The DNS expected orders to be processed and implemented.
A resident with sleep apnea was found to have a dusty BIPAP machine with improperly stored tubing and mask, and no distilled water available. Staff interviews revealed inconsistencies in cleaning responsibilities, and there was no physician's order for the machine. The RNCM acknowledged the lack of proper maintenance and oversight, placing the resident at risk for breathing complications.
A resident with end-stage renal disease did not receive prescribed medications before dialysis, as staff administered only a pain medication prior to departure. The resident's other morning medications were given after returning from dialysis, contrary to physician orders. Additionally, Pre/Post Dialysis Communication forms were often inaccurate or incomplete, with staff acknowledging inconsistencies and lack of proper documentation.
A facility failed to address a pharmacist's recommendation to increase a resident's Melatonin dosage due to insomnia. Despite the pharmacist's suggestion to increase the dosage from 1 mg to 3 mg, the clinical record showed no follow-up action. Staff interviews confirmed that the provider did not respond to the recommendation, leading to delays in addressing the resident's medication needs.
The facility failed to maintain proper waste containment and sanitation in the garbage storage area. Observations revealed uncovered dumpsters with overflowing garbage bags spilling onto the ground. The Dietary Manager acknowledged the issue, noting that garbage collection occurred three times a week, and the overflow had accumulated since the previous week. The Maintenance Director confirmed the facility's policy to keep garbage contained and the area clear of debris, and staff were educated on maintaining closed dumpsters.
The facility failed to follow infection control practices for two residents, one with a PEG tube and another with a Foley catheter. Staff did not adhere to enhanced barrier precautions, such as wearing gowns, during hands-on care, despite the presence of instructions and the need for such precautions due to the residents' medical conditions.
The facility did not ensure that CNAs received the mandatory 12 hours of annual in-service training. A review of records for five staff members showed no completed training hours, which was confirmed by the DNS and Administrator.
The facility failed to provide written transfer notices with appeal rights to two residents and their representatives when they were transferred to the hospital. One resident, admitted with a stroke and swallowing difficulties, and another with gallbladder issues, were both transferred without receiving the required notifications. The DNS confirmed that these notifications were not being provided, despite expectations.
The facility failed to provide two residents with a written bed hold notification, including reserved payment details, when they were transferred to the hospital. One resident with a stroke and swallowing difficulties and another with gallbladder issues did not receive the required notice. The DNS confirmed the oversight.
A resident with chronic kidney disease and requiring dialysis requested bed rails for bed mobility upon admission. Despite being cognitively intact and needing moderate assistance, the resident had to use the headboard to reposition themselves and waited weeks for bed rails. A public complaint and grievance form highlighted the delay. An LPN recalled the request and claimed an assessment was done, but the DNS stated no assessment was completed, although a physician order was initiated. The administrator acknowledged the delay in providing the bed rails.
A facility failed to allow a resident to return after a therapeutic leave, exceeding the bed-hold policy. The resident, with diagnoses including heart failure and homelessness, was out of the facility and upon return, was informed of discharge against medical advice. Despite returning to her/his room, the resident was escorted out, and a complaint was filed alleging belongings were locked up. The administrator confirmed the resident was not permitted to return after being late from leave.
A resident with hypertension was discharged from a facility and transported to another state without a meal for the extended journey. The discharge instructions did not include a meal provision, and staff confirmed that no meal was sent with the resident. The facility administrator acknowledged this oversight.
A resident admitted with cataracts in both eyes did not receive timely optometry services as outlined in their care plan. Despite requests for an eye exam since admission, the facility failed to schedule an ophthalmology appointment until recently. A staff member acknowledged the delay in scheduling the necessary vision appointment.
A resident admitted with congestive heart failure and diabetes had dental care needs due to being edentulous. Despite requesting a dental exam and dentures, the facility failed to schedule any dental appointments from admission in 2022 until new orders in 2023. Observations confirmed the resident was missing most natural teeth, and staff acknowledged the delay in scheduling a dental appointment.
A resident with cognitive impairment and aphasia eloped from the facility due to inadequate re-evaluation of elopement risks and care plan interventions. Despite being identified as an elopement risk, the resident's exit-seeking behaviors were not consistently documented or communicated among staff, leading to an immediate jeopardy situation. The facility's Wandering and Elopement policy was not effectively implemented, resulting in the resident's continued missing status.
The facility did not develop or present a QAPI plan to the SSA and lacked documentation of an ongoing QAPI program. The administrator confirmed the absence of these essential components during the survey.
The facility did not conduct quarterly QAA meetings and failed to involve the Medical Director in quality assurance activities. This was confirmed by the Administrator, who acknowledged the lack of meetings and the Medical Director's absence, putting residents at risk of not receiving optimal care.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment, as evidenced by several deficiencies observed in the dining rooms, hallways, and resident rooms. In the Enhanced Care Unit (ECU) dining room, there were significant tripping hazards due to missing and damaged linoleum flooring. Staff confirmed that these issues had been present for some time and had been reported to maintenance, yet no warnings were in place to alert residents of the hazards. Additionally, various resident rooms and shared spaces exhibited damage such as scrapes on walls and black marks on floors, further detracting from a homelike environment. Resident 68, who was admitted with a diagnosis of cerebral infarction, experienced discomfort due to the inability to regulate the temperature in her/his room. The room was consistently cold, particularly from midnight to 8:00 AM, despite attempts by staff to adjust the thermostat. The Maintenance Director acknowledged the difficulty in maintaining a comfortable temperature and noted that unauthorized adjustments to the thermostat could exacerbate the issue. Other residents in nearby rooms also reported similar temperature concerns, indicating a broader issue with temperature regulation in the facility.
Failure to Enforce Smoking Policies and Timely Assessments
Penalty
Summary
The facility failed to ensure timely smoking assessments and safe storage of smoking materials for three residents, leading to potential accident hazards. Resident 22, admitted with chronic heart failure and diabetes, was assessed as safe to smoke independently. However, observations revealed that Resident 22 kept smoking materials in their pocket, contrary to the facility's policy requiring these materials to be locked up. Staff interviews confirmed that Resident 22 did not comply with the policy, and there was no evidence that the facility enforced the safe storage requirement. Resident 50, with end-stage kidney disease and diabetes, was also assessed as safe to smoke independently. However, the initial smoking assessment was missing, and the quarterly assessment was delayed. Observations showed that Resident 50 kept smoking materials with them, and staff interviews indicated a lack of clarity and enforcement regarding the storage policy. Despite being aware of the policy, staff acknowledged that Resident 50 did not comply with the requirement to lock up smoking materials. Resident 60, diagnosed with schizoaffective disorder and kidney disease, was found to have no initial smoking assessment or care plan related to smoking until months after admission. Observations and interviews revealed that Resident 60 kept smoking materials unsecured, and staff were uncertain about the current smoking policy. The facility's Director of Nursing Services acknowledged the delay in assessment and the absence of a care plan, highlighting a systemic issue in policy enforcement and resident compliance.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in prolonged call light response times for several residents. Resident 26, admitted with morbid obesity and diabetes, reported call light response times of up to 45 minutes, with logs showing multiple instances of delays exceeding 30 minutes. Similarly, Resident 22, with morbid obesity and a right leg amputation, experienced delays of up to an hour, leading to sitting in soiled briefs. Resident 57, diagnosed with lung and brain cancer, also faced extended wait times, prompting attempts to self-manage care. Interviews with staff revealed that call light response times were longer during periods of short staffing, which occurred occasionally. Staff members acknowledged that not all personnel assisted with answering call lights, contributing to the delays. The facility's administrator and director of nursing services confirmed the expectation for call lights to be answered within 20 minutes and recognized the failure to meet this standard for the affected residents. A review of the facility's staffing reports indicated that the facility did not meet mandatory state minimum CNA ratios on several occasions, particularly during the day shift. Additionally, the facility struggled to meet state bariatric staffing ratios on multiple dates. The staffing coordinator admitted difficulties in covering shifts, especially with last-minute call-offs, and the facility's leadership acknowledged the challenges in maintaining adequate staffing levels to meet state requirements.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to ensure that each Certified Nursing Assistant (CNA) received annual performance reviews, as evidenced by the lack of completed reviews for five randomly selected CNAs. During an interview and record review, it was discovered that the personnel profile records for these CNAs did not contain any annual performance reviews. Staff 2, the Director of Nursing Services (DNS), confirmed that if the reviews were not in the personnel profile folders, they had not been completed. Both Staff 1, the Administrator, and Staff 2 acknowledged this oversight, which placed residents at risk for receiving care from potentially incompetent staff.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the proper storage, labeling, and disposal of drugs and biologicals, as observed in three out of four medication carts. During an early morning observation, a diabetic/treatment cart was found to contain expired and improperly labeled medications, including Naloxone Nasal Spray and Lantus insulin without an open date. Additionally, an unlabeled bottle of insulin and a Humulin Kwik Pen with an expired open date were found. An unlabeled tube of Solosite Wound Treatment Gel was also discovered with an expired date. Furthermore, the medication cart was left unlocked and unattended outside the dining room, posing a risk to residents as several staff members and a resident walked past it. Further inspection revealed a medication storage card containing Lorazepam tablets for a resident who no longer had an order for the medication, along with three loose tablets of unknown ingredients. Staff confirmed these medications should have been destroyed. Additionally, multiple opened medicated creams and ointments were found without open dates on the labels, and staff was uncertain if open dates were required. The Director of Nursing Services (DNS) stated that staff was expected to adhere to the facility's policy for storing, labeling, and destroying medications and biologicals.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide necessary dental services for a resident who was admitted with diagnoses including dysphagia and pneumonitis. The resident, who had severe cognitive impairment and required substantial assistance for oral hygiene, had not been seen by a dentist since admission. Observations revealed the resident had jagged, broken, and decayed teeth, along with thick accumulations of oral secretions. A family member noticed the buildup on the resident's teeth and reported it to the facility staff, but dental care was not provided. Staff interviews revealed that the resident's teeth were swabbed rather than brushed due to a choking risk, and the resident was not seen by a dentist during the last visit to the facility. The Director of Nursing Services confirmed the inaccuracy of the resident's MDS and acknowledged the need for dental care. The deficiency was identified as a failure to provide timely dental services, placing the resident at risk for unmet dental needs.
Failure to Implement Compression Stocking Order for Resident with Edema
Penalty
Summary
The facility failed to provide appropriate care and treatment for a resident with edema, as observed during a survey. The resident, admitted in November 2024 with conditions including deep vein thrombosis, atrial fibrillation, and high blood pressure, reported discomfort due to swelling in the legs. Despite a provider's order for compression stockings issued approximately four weeks prior, the resident did not receive them, and they were not observed on the resident's lower extremities. A registered nurse was unaware of the order, but located a progress note from December 6, 2024, indicating an order for Tubigrip, a form of compression dressing. The LPN Resident Care Manager acknowledged that the order had not been followed up on or implemented due to an oversight. The Director of Nursing Services stated that she expected provider orders to be processed and implemented.
Failure to Maintain and Support Resident's BIPAP Machine
Penalty
Summary
The facility failed to ensure proper respiratory care and maintenance of equipment for a resident diagnosed with sleep apnea who utilized a BIPAP machine. The resident was admitted with diagnoses including anxiety and depression, and the care plan indicated the need for a CPAP/BIPAP machine, which required regular cleaning. However, observations revealed that the BIPAP machine was dusty, and the tubing and mask were improperly stored in a drawer under magazines and a cracker box. The resident reported that staff did not clean the device or ensure it had distilled water, and there was no evidence of a physician's order for the BIPAP machine in the clinical record. Staff interviews confirmed that the resident used the BIPAP machine at night, but there was inconsistency in the cleaning responsibilities, with night shift staff reportedly responsible for cleaning. Despite this, the machine remained dusty, and there was no distilled water available. The RNCM acknowledged the lack of orders for the BIPAP machine and the inadequate cleaning of the equipment. This deficiency placed the resident at risk for breathing complications due to the improper maintenance and oversight of the respiratory equipment.
Failure to Administer Medications and Complete Dialysis Communication Forms
Penalty
Summary
The facility failed to administer medications and ensure accurate completion of communication forms for a resident requiring dialysis. The resident, diagnosed with end-stage renal disease and diabetes, was scheduled for dialysis on Tuesdays, Thursdays, and Saturdays. Despite physician orders for specific medications to be administered before dialysis, the resident only received a pain medication prior to leaving the facility. Staff members confirmed that the resident's other morning medications were not administered until after returning from dialysis, which was contrary to the prescribed schedule. Observations and interviews revealed that the resident routinely left for dialysis without receiving the necessary medications, which were intended to be given before the procedure. Staff members, including LPNs and a CMA, acknowledged that the medications were either marked as administered or noted as the resident being out, despite not being given at the correct times. This practice was not known to the RNCM and DNS, who expected staff to seek clarification on medication administration for dialysis days. Additionally, the facility failed to ensure the accuracy and completion of Pre/Post Dialysis Communication forms. The forms were often inaccurate, incomplete, or not returned from the dialysis center. Staff members admitted to inconsistencies in the forms, with two different versions being used, and acknowledged that the forms were not always transcribed or uploaded into the electronic system as required. The RNCM and DNS were unaware of these issues, indicating a lack of oversight in the communication process for dialysis care.
Failure to Address Pharmacist Recommendations for Medication Adjustment
Penalty
Summary
The facility failed to ensure that pharmacist recommendations were addressed for a resident reviewed for unnecessary medications. The resident was admitted with a diagnosis of insomnia and was prescribed Melatonin 1 mg at bedtime. In November, the pharmacist recommended increasing the dosage to 3 mg due to the resident's limited sleep duration of one to four hours per night. However, there was no indication in the clinical record that this recommendation was addressed. Interviews with staff revealed that the facility did not receive a response from the resident's provider regarding the pharmacist's recommendation, and it was noted that the provider did not consistently respond to such recommendations, causing delays in follow-up.
Improper Garbage Disposal and Sanitation Issues
Penalty
Summary
The facility failed to ensure that waste was properly contained in dumpsters and that the garbage storage area was maintained in a sanitary condition. During an observation, the outside dumpsters adjacent to the kitchen door were found uncovered, with garbage bags full of kitchen and resident care waste spilling over and covering the ground around the dumpsters. A minimum of 20 bags of garbage were piled on the ground in the parking lot in front of the dumpsters. This situation was acknowledged by the Dietary Manager, who noted that the garbage collection usually occurred three times a week, and the overflow had accumulated since the previous week. The Maintenance Director confirmed that the facility's policy required garbage to be contained within the dumpsters with lids closed and the area around the dumpsters to be clear of garbage bags and debris to limit accessibility to pests. He stated that an additional dumpster was being used to contain all of the garbage and that staff had been educated on the importance of keeping the garbage in the dumpsters with the lids closed. The Director of Nursing Services also stated that she expected the facility's garbage to be contained in the dumpsters.
Failure to Follow Infection Control Practices for Residents with Special Needs
Penalty
Summary
The facility failed to adhere to infection control practices for two residents, leading to a risk of cross-contamination. Resident 36, who has severe cognitive impairment and requires significant assistance for toileting hygiene, was observed with a soiled brief. Staff 35, a CNA, entered the resident's room without donning the required personal protective equipment (PPE) such as a gown, despite the posted instructions for enhanced barrier precautions due to the resident's PEG tube. Staff 35 admitted to not wearing a gown while providing care, which included changing the resident's brief and linens. Similarly, Resident 49, who has a Foley catheter, did not have instructions for enhanced barrier precautions posted outside their room. Staff 41, another CNA, provided hands-on care, including a brief change, wearing only gloves and no additional PPE. The facility's infection preventionist and administrator confirmed that enhanced barrier precautions were necessary for Resident 49 due to the presence of the Foley catheter, but these precautions were not followed.
Failure to Provide Required In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistant (CNA) staff received the required 12 hours of in-service training annually. This deficiency was identified for five randomly selected staff members. During an interview and record review, it was revealed that the personal profile records for these staff members showed no completed training hours. The Director of Nursing Services (DNS) confirmed that if no records were found in the personal profile folders, the training was not completed. Both the Administrator and the DNS acknowledged the lack of completion of the required training hours for the staff members involved.
Failure to Provide Transfer Notices with Appeal Rights
Penalty
Summary
The facility failed to provide written transfer notices with appeal rights to residents and their representatives when residents were transferred to the hospital. This deficiency was identified for two residents who were hospitalized. Resident 80, admitted in February 2024 with a stroke and swallowing difficulties, was transferred to the hospital on October 5, 2024. A review of Resident 80's health record showed no evidence of a transfer notice with appeal rights being provided in writing to the resident or their representative. Similarly, Resident 81, admitted in October 2024 with gallbladder calculus and abdominal pain, was transferred to the hospital on October 31, 2024. Again, there was no documentation in Resident 81's health record indicating that a transfer notice with appeal rights was provided in writing. Staff 2, the Director of Nursing Services (DNS), confirmed that transfer notifications with appeal rights were not being provided to residents or their representatives upon hospital transfer, despite it being her expectation that such notifications should be given.
Failure to Provide Bed Hold Notification
Penalty
Summary
The facility failed to provide two residents with a written bed hold notification, including information on reserved bed hold payment, at the time of their transfer to the hospital. Resident 80, who was admitted in February 2024 with a stroke and difficulty swallowing, was discharged to the hospital on October 5, 2024, without receiving the required written notice. Similarly, Resident 81, admitted in October 2024 with gallbladder calculus and abdominal pain, was transferred to the hospital on October 31, 2024, without receiving the written bed hold policy. Staff 2, the Director of Nursing Services (DNS), confirmed that the written bed hold policy was not provided to either resident or their representatives at the time of their hospital transfers.
Failure to Provide Bed Rails for Resident Mobility
Penalty
Summary
The facility failed to provide bed rails needed for bed mobility for a resident, which placed the resident at risk of activities of daily living (ADL) decline. The resident, who was admitted with chronic kidney disease and required dialysis, was cognitively intact with a BIMS score of 15 and needed moderate assistance with bed mobility. Upon admission, the resident requested bed rails to assist with bed mobility, as documented in a nursing admission note. Despite this request, the resident had to use the headboard to reposition themselves and waited several weeks before bed rails were installed. A public complaint was filed on 6/28/24, indicating the resident's request for bed rails. A grievance form filed by the resident on 5/29/24 reiterated the request for bed rails. Staff interviews revealed that an LPN recalled the resident's request and stated that an assessment was completed, and a physician's order was requested. However, the Director of Nursing Services (DNS) stated that a bed rail assessment was not completed, although a physician order was initiated on 5/29/24. The facility administrator acknowledged the delay in providing the bed rails, which were not installed until 5/29/24, despite the resident's request at the time of admission.
Failure to Permit Resident Return After Therapeutic Leave
Penalty
Summary
The facility failed to permit a resident to return after a hospitalization or therapeutic leave, exceeding the bed-hold policy, for one of the four sampled residents reviewed for discharge. The resident, who was admitted in December 2023 with diagnoses including absence of the right foot, heart failure, and cocaine abuse, was noted to be homeless and staying in her/his car or motels. On March 4, 2024, a progress note indicated the resident was out of the facility at her/his mother's house, and by March 5, 2024, staff had left a voice message for the resident to return. On March 9, 2024, the resident returned to the facility early in the morning after being out since March 3, 2024, and was informed by a staff RN that she/he was discharged per facility policy. Despite this, the resident went to her/his previous room and went to bed, prompting staff to call the on-call manager. A public complaint filed on May 3, 2024, alleged that upon the resident's return, her/his belongings were locked up, and she/he was informed of being discharged against medical advice (AMA) and was escorted out of the facility. The facility's administrator confirmed that the resident was not permitted to return after being late from therapeutic leave.
Failure to Provide Meal During Resident Discharge
Penalty
Summary
The facility failed to ensure that meals were provided for a resident during discharge, which was identified as a deficiency. Resident 5, who had been admitted to the facility in December 2023 with a diagnosis of hypertension, was discharged on January 11, 2024, to another state. The discharge instructions indicated that the resident was to be transported to a new nursing facility, with an expected travel time from 10:15 AM to 5:30 PM. However, there was no indication that a meal was ordered or provided for the resident during this extended transport. Staff 10, a CNA, confirmed that the resident was sent out by medical transport without a meal. The facility administrator, Staff 1, acknowledged that the staff did not send a meal with the resident for the transport.
Failure to Provide Timely Optometry Services
Penalty
Summary
The facility failed to provide timely optometry services for a resident who was admitted in March 2022 with diagnoses including congestive heart failure and diabetes mellitus. The resident's initial care plan, dated April 5, 2022, indicated the presence of cataracts in both eyes and included an intervention to refer the resident for an eye exam. Despite this, a progress note from June 17, 2023, revealed that a staff member had discussed scheduling a vision appointment with the resident, but there was no documentation of any appointments being made. The resident reported on July 9, 2024, that they had requested an eye exam since admission, but the facility only recently scheduled an ophthalmology appointment. A staff member acknowledged on July 17, 2024, that the facility had not made a timely vision appointment for the resident after their admission.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to ensure routine dental services were provided for a resident who was admitted in March 2022 with diagnoses including congestive heart failure and diabetes mellitus. The resident's initial care plan in April 2022 indicated dental care needs due to being edentulous, with an intervention to obtain a dental consult. Despite the resident requesting a dental exam in August 2022, and a progress note in June 2023 indicating a discussion about scheduling a dental appointment, no appointments were documented until new orders were issued in August 2023. Observations in July 2024 confirmed the resident was missing most natural teeth and had requested dentures since admission, but the facility had not scheduled any dental appointments. Staff acknowledged the delay in making a timely dental appointment for the resident.
Failure to Address Elopement Risk for Cognitively Impaired Resident
Penalty
Summary
The facility failed to re-evaluate elopement risks and modify care plan interventions for a resident with cognitive impairment and aphasia, leading to an immediate jeopardy situation. The resident, admitted in April 2024 with a history of stroke, dysphagia, and severe cognitive impairment, exhibited wandering and exit-seeking behaviors. Despite being identified as an elopement risk, the resident's care plan did not adequately address these behaviors, and staff failed to consistently document or communicate the resident's exit-seeking tendencies. On June 12, 2024, the resident eloped from the facility, having been last seen at 6:30 AM. Staff initiated a search and contacted law enforcement when the resident was not found. Interviews revealed that staff were aware of the resident's elopement risk but did not consistently chart or communicate these behaviors. The resident had previously been observed unsupervised in the parking lot, and staff had overheard the resident expressing a desire to leave. However, these incidents were not adequately addressed in the care plan or communicated among staff. The facility's failure to re-evaluate the resident's elopement risk and modify care plan interventions resulted in the resident's elopement and placed other residents at risk. Staff interviews indicated a lack of awareness and communication regarding the resident's behaviors, contributing to the deficiency. The facility's Wandering and Elopement policy was not effectively implemented, as staff did not consistently monitor or document the resident's exit-seeking behaviors, leading to the resident's continued missing status.
Removal Plan
- All current residents with cognitive impairment will have an elopement risk assessment completed
- Residents with an identified elopement risk will have care plans reviewed for effective interventions and updated as needed
- Behavior monitors will be created and/or updated to reflect identified elopement risks and interventions
- Weekly audits to be conducted of elopement risks for care plan, interventions and behavior monitor
- Audits will be brought to QAPI for review
- Nursing staff were to update themselves regarding wandering protocol at the start of every shift
- Residents with known elopement/wandering risks observed to be exit seeking would be monitored by staff, who were not to leave the resident and tell other staff to alert the charge nurse
- Nurses were to chart any type of exit seeking behaviors
- At the beginning of each shift, all care staff will do walking rounds and all residents must have visual checks completed by staff
- Elopement risk assessments will be completed on admission, quarterly and with any behavioral changes
Lack of QAPI Plan and Program
Penalty
Summary
The facility failed to develop and present a Quality Assurance and Performance Improvement (QAPI) plan to the State Survey Agency (SSA) and did not provide documentation or evidence of an ongoing QAPI program. This deficiency was identified through interviews and record reviews. The facility's administrator, referred to as Staff 1, acknowledged the absence of a QAPI plan and program during the survey.
Failure to Conduct Quarterly QAA Meetings and Involve Medical Director
Penalty
Summary
The facility failed to conduct quarterly Quality Assessment and Assurance (QAA) committee meetings and did not include the Medical Director in the quality assurance process. This deficiency was identified through interviews and record reviews, which revealed a lack of evidence or documentation supporting the occurrence of these meetings. Staff 1, the Administrator, acknowledged that the QAA committee had not met quarterly and confirmed the absence of the Medical Director's involvement in the quality assurance activities. This oversight placed residents at risk of not receiving the necessary care and services for optimal outcomes.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
