Chehalem Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Newberg, Oregon.
- Location
- 1900 E. Fulton Street, Newberg, Oregon 97132
- CMS Provider Number
- 385199
- Inspections on file
- 23
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Chehalem Post Acute during CMS and state inspections, most recent first.
Two residents experienced multiple room changes without receiving the written advance notice required by facility policy, which mandates written notification with reasons for any room or roommate change. One resident with quadriplegia and aphasia had a designated family responsible party who was not given written notice before a room move, as confirmed by both the family member and facility leadership. Another resident with dementia and cognitive communication deficits underwent several room changes, with no documentation of written notification in the clinical record, and the Administrator acknowledged that written notices were not provided in these instances.
Two dependent residents did not receive scheduled showers needed to maintain hygiene and dignity. One resident with quadriplegia, aphasia, and severe cognitive impairment was care planned for staff-assisted showers but, over multiple scheduled opportunities, received only a few showers, some bed baths, and no documented make-up showers for several missed or refused shower days, despite family complaints of strong body odor and greasy hair and staff acknowledgment that showers were important. Another resident with diabetes, metabolic encephalopathy, and bowel and bladder incontinence, who preferred showers and was scheduled for twice-weekly bathing, had only one shower documented over about a month, with no evidence of additional offers when showers were missed. Staff interviews revealed that residents rarely refused showers, that agency CNAs frequently documented refusals without offering showers, and that heavy reliance on agency staff and workload issues, especially on evening and weekend shifts, led to showers not being completed as scheduled.
A former LPN continued to receive confidential resident information, such as names, room numbers, and admission details, through a phone app for about a month after leaving employment. The administrator confirmed the oversight, as the app used for staff communication was not updated to remove the former employee, resulting in a breach of resident privacy.
A facility-wide assessment was found to be incomplete and lacking accurate information on staffing needs, resident ADL assistance, transmission-based precautions, resident demographics, and agency staff usage. The Administrator confirmed the assessment was not comprehensive and did not address these critical areas.
The facility did not ensure its QAPI program addressed multiple quality concerns, including insufficient staffing, unresolved grievances, unmet memory care regulations, medication and pharmacy service delays, construction-related disruptions, inadequate infection control, and lack of timely lab services. Leadership acknowledged these issues were not recognized or acted upon by the QAPI process.
The facility did not have an RN on duty for at least eight consecutive hours on multiple occasions, as confirmed by staff records and administrator acknowledgment.
The facility did not have a qualified infection preventionist overseeing the infection prevention and control program for an extended period. Documentation and staff interviews confirmed a gap of several months without a certified infection preventionist, and a registered nurse assigned to the role did not receive required training before being terminated.
The facility did not maintain resident privacy and confidentiality when a terminated staff member continued to receive confidential information through a phone app, and during a facility-wide flooring replacement, two residents received personal care without adequate privacy due to insufficient dividers. Staff and residents reported concerns about the lack of privacy, and the available measures were not sufficient to protect resident dignity during personal care.
The facility did not complete reference checks for three newly hired staff members, including an LPN and two CNAs, as required by its abuse prevention policy. Human Resources and the Administrator confirmed that reference checks had not been performed for new hires since a change in ownership, contrary to facility policy.
The facility did not maintain adequate nursing staff to meet resident care needs, resulting in prolonged call light response times, delayed medication administration, and incomplete care, especially for residents with high acuity and those requiring two-person assistance. Both residents and staff reported frequent short staffing, with management aware of the ongoing issues but not providing timely solutions.
Annual performance reviews were not completed for three CNAs who had been employed for over a year. When requested, no documentation of these reviews was provided, and the DNS confirmed that the required evaluations had not been conducted within the past 12 months.
The facility did not ensure timely procurement and administration of routine medications, resulting in multiple residents missing or receiving late doses of essential medications such as pain relievers, antihypertensives, and antidepressants. Delays were caused by pharmacy communication issues, staff not verifying orders, and workflow disruptions during a renovation project, with staff shortages further contributing to the problem.
Surveyors observed a treatment cart and a medication cart left unlocked and unattended in the hallway near the nurses station. The treatment cart contained insulin, creams, and other supplies, while the medication cart contained resident medications. In both cases, an LPN admitted to leaving the cart unsecured, and the DON confirmed that carts are expected to be locked when unattended.
Staff failed to perform proper hand hygiene during meal service, did not implement a required water management program for water-borne pathogens, and did not follow CDC Enhanced Barrier Precautions for two residents with indwelling catheters, resulting in improper disposal of PPE outside resident rooms.
Two residents received psychotropic medications, including trazodone and quetiapine fumarate, without being informed of the risks and benefits or providing consent. Staff and nursing leadership confirmed that the required discussions and documentation of informed consent did not occur prior to administration.
A resident with dementia had a critical low hemoglobin level identified by lab testing, but the result was not communicated to the ordering practitioner due to technical and communication issues. The critical value remained unreviewed for several days, during which the resident developed significant symptoms and was later hospitalized.
A resident with severe cognitive impairment and a diagnosis of dementia was offered and refused a COVID-19 vaccine without the facility contacting or obtaining consent from the resident's Power of Attorney, despite facility policy requiring representative consent for residents unable to make their own medical decisions.
Two residents experienced deficiencies in environmental cleanliness and room repair, including a bathroom with dried feces, an electric outlet with exposed wires, and a window with missing trim and jagged edges. Housekeeping and maintenance staff were aware of these issues, and residents and family members reported ongoing concerns about cleanliness and safety.
A resident with quadriplegia and bowel incontinence did not have their preference for suppositories over oral medications documented in their care plan. As a result, agency staff were unaware of this preference and administered oral medications, causing the resident distress. Staff interviews confirmed the omission and the resident's ongoing requests for suppositories first.
A resident with schizophrenia and major depressive disorder received the wrong antidepressant for 25 days after an LPN transcribed a provider order for Celexa, despite the resident not previously being on that medication. The original medication, escitalopram, was discontinued and replaced in error, and the mistake was not identified until a psychotropic drug review.
Three residents experienced deficiencies in medication management, including lack of bowel movement monitoring and administration of prescribed laxatives, failure to clarify and administer sliding scale insulin for elevated blood glucose, and a medication transcription error resulting in the wrong antidepressant being given for several weeks. Staff interviews and record reviews confirmed that required monitoring, documentation, and order clarifications were not performed.
A resident with dementia experienced an unwitnessed fall. Although staff checked vital signs, assessed for injuries, and started neuro checks, a required fall assessment was not completed, as later acknowledged by the DNS.
A resident with diabetes had a physician order for a stool sample to rule out c-diff. Staff collected the sample but mislabeled it with another resident's name, requiring a new sample to be obtained and causing a delay in lab results.
A resident with diabetes and heart failure, who was cognitively intact, was not given a pneumococcal vaccine despite providing verbal consent after education from the Infection Preventionist. The vaccine was not administered due to lack of follow-up.
The facility did not consistently post accurate and complete daily nurse staffing information, with several days showing missing or incorrect data regarding census and staff numbers. This was acknowledged by the administrator after review.
A resident with Alzheimer's and paranoid schizophrenia kicked another resident's walker, causing a fall and serious injury. Despite known behavioral issues, the facility failed to adequately monitor or separate the residents, leading to the incident. Staff were unaware of the need for increased supervision, resulting in a deficiency in resident safety.
A resident with dementia and visual disturbances was moved to a different room without prior written notice to the resident or their family, leading to increased anxiety and aggression. The facility's administrator confirmed the lack of notification and documentation regarding the room change.
A facility failed to follow care plan interventions for a resident requiring two-person assistance with a gait belt for transfers, leading to a potential risk of injury. An agency CNA attempted a one-person transfer, contrary to the care plan, resulting in the resident being returned to bed unsuccessfully. The resident later reported being dropped, complained of pain, and was diagnosed with a distal femur fracture at the hospital. Attempts to contact the CNA for further information were unsuccessful, and an LPN confirmed the transfer was not conducted correctly.
A resident with dementia and behavioral issues verbally and physically abused another resident during a bingo activity, resulting in a small bruise and feelings of abuse. The incident was acknowledged by the facility's administrator and DNS.
Failure to Provide Required Written Notice of Room Changes
Penalty
Summary
The deficiency involves the facility’s failure to provide written advance notice of room changes to residents or their responsible parties, as required by the facility’s Room/Roommate and Change Notification Policy dated 8/1/24. That policy states residents have the right to receive written notice, including the reason for the change, before a room or roommate change occurs. For one resident admitted in 7/2025 with quadriplegia and aphasia, the admission profile/face sheet identified a family member as the responsible party. The clinical record showed this resident was moved to a different room on 8/21/25, but progress notes from 7/2025 through 9/2025 contained no documentation that written notification of the room change was provided to the responsible family member. During interview, the family member stated she did not receive written notification before the move, and the DNS and Administrator confirmed that no written notification had been provided. A second resident, admitted in 2/2025 with dementia and cognitive communication deficits, was identified as their own responsible party. The census showed this resident had multiple room changes on 12/20/25, 12/22/25, 12/30/25, and 1/3/26. On interview, the resident’s communication was unintelligible and responses unreliable when asked about the room changes. Review of the clinical record revealed no documentation of written notification for any of these room changes. The Administrator reported that residents or their responsible parties should receive written notification of room changes prior to being moved and confirmed that no written notifications were provided for this resident’s room changes.
Failure to Provide Scheduled Showers and Hygiene Care for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure dependent residents received showers as needed to maintain personal hygiene and dignity, contrary to its Activities of Daily Living policy requiring necessary services for grooming and hygiene. One resident with quadriplegia, aphasia, severe cognitive deficit, and total dependence for bathing was care planned to receive one-person total assistance for showers, but the care plan did not specify shower frequency. Bathing task logs for a one‑month period showed this resident was scheduled for showers twice weekly on Wednesdays and Saturdays, with 10 shower opportunities. The resident received showers on only four of those dates, two bed baths on two dates, and had no documented showers or make‑up showers on three Saturdays and one additional date when a shower was refused. There was no evidence in the clinical record that missed showers were made up, and a family grievance documented concerns about strong body odor and greasy hair and face, as well as a request to increase shower frequency. Interviews with CNAs and nursing staff confirmed that the resident was dependent on staff for showering, usually did not refuse showers, and that the expected practice was to make up missed showers later the same day or the next day, and to offer a bed bath if a shower was refused. Staff reported that showers were important for this resident due to sweating, smelly hair, and oily skin. Staff also acknowledged that showers were not consistently completed, particularly on Saturdays, and attributed this to heavy reliance on agency CNAs. The Assistant DNS/Resident Care Manager and DNS were aware that scheduled showers were missed during the review period, and observations over several days showed the resident in bed or in a Geri chair with oily facial skin. A second resident with diabetes, metabolic encephalopathy, bowel and bladder incontinence, and total dependence on staff for bathing was care planned to receive showers twice weekly and as necessary, with a preference for showers. The shower schedule listed this resident for Wednesday and Saturday evening showers, but bathing task logs over a one‑month period showed only one documented shower. Progress notes contained no evidence of additional shower opportunities when showers were refused or not provided. During observations, the resident was noted in bed with greasy hair and wearing a gown, and reported not being showered regularly, estimating the last shower was about a month prior, and stating that staff had not offered showers in a long time and that refusals were rare. CNAs confirmed the resident was frequently soiled, rarely refused showers, and that agency CNAs often documented refusals without actually offering showers. Staff also reported that scheduled showers were often not completed due to workload, staffing patterns, and the need for two staff and a mechanical lift for this resident, and the DNS and regional clinical leader confirmed that the last documented shower date for this resident was not acceptable.
Failure to Protect Resident Record Privacy After Staff Termination
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of resident records by continuing to send confidential resident information to a former staff member, an LPN, via a phone application after her employment had ended. Documentation confirmed that the former LPN's last day at the facility was 6/19/25, yet she continued to receive private data, including resident names, room numbers, new admissions, and behavioral information, for approximately one month after her departure. The administrator acknowledged that the phone app used for internal communication was not updated to remove the former staff member, resulting in the ongoing disclosure of sensitive resident information.
Incomplete Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct and complete a comprehensive facility-wide assessment necessary to ensure competent care for residents during both routine operations and emergencies. Review of the facility's assessment dated 3/19/25 revealed it was not comprehensive and lacked accurate information in several key areas, including how the assessment was used to address staffing needs and competencies, the percentage of residents on transmission-based precautions, the number of residents requiring assistance with activities of daily living (ADLs) based on average census, the ethnic, cultural, and religious makeup of the resident population, and the high usage of agency staff. During an interview, the Administrator acknowledged these deficiencies and confirmed that the assessment did not contain accurate or complete information in the specified areas. No additional information was provided.
Failure to Implement Effective QAPI Program to Address Quality Deficiencies
Penalty
Summary
The facility failed to ensure its Quality Assurance and Performance Improvement (QAPI) program effectively implemented action plans to address identified quality deficiencies. The QAPI policy outlined a systematic, comprehensive, and data-driven approach, but interviews and record reviews revealed that the program did not recognize or address several significant concerns. These included insufficient staffing based on resident acuity, unresolved resident grievances related to staffing, unmet regulatory requirements for the memory care unit, delays in residents receiving medications, lack of pharmacy services, issues caused by facility construction such as resident displacement and loss of privacy, inadequate infection control practices not aligned with CDC guidelines, delays in lab services, and the absence of an Infection Control Preventionist for a period of time. These deficiencies were acknowledged by facility leadership during interviews.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was present for at least eight consecutive hours on six specific days, as identified through a review of Direct Care Staff Daily Reports. The dates without required RN coverage were 7/20/24, 9/16/24, 9/28/24, 1/4/25, 1/5/25, and 2/15/25. This deficiency was acknowledged by the facility administrator during interviews conducted on 3/26/25. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency were provided in the report.
Failure to Maintain Qualified Infection Preventionist
Penalty
Summary
Surveyors determined that the facility failed to have a qualified and trained infection preventionist responsible for the infection prevention and control program. Documentation provided showed that the previous infection preventionist's employment ended on 1/5/24, and the next infection preventionist did not start until 10/29/24, resulting in a gap of 298 days without a certified infection preventionist. During this period, a registered nurse was asked to serve as the infection prevention nurse but did not receive any education or training for the role and was terminated before the new infection preventionist began. Facility staff confirmed that there was no infection preventionist in place during this time.
Failure to Ensure Resident Privacy and Confidentiality During Staff Termination and Facility Construction
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of resident records and personal care for two residents and did not ensure the security of its record system. After a staff member was terminated, she continued to receive confidential resident information, including admissions, discharges, and updates on resident conditions, via a phone application for nearly a month post-termination. The Director of Nursing Services (DNS) acknowledged that the expectation was for terminated staff to be removed from such communications immediately upon their last day of employment, but this did not occur. During a facility-wide flooring replacement, all residents were displaced from their rooms and relocated to common areas such as the main dining room, therapy room, and living room. During this period, there was inadequate privacy for residents while personal care was provided. Makeshift dividers using IV poles and blankets were used, but there were not enough to provide privacy between each resident. Staff reported that dividers were primarily used to separate genders and around commodes, but not between individual residents, resulting in residents receiving personal care and using bedside commodes without adequate privacy from others in close proximity. Both residents involved were cognitively intact and reported a lack of privacy during their stay in the therapy room. Staff confirmed that concerns about privacy were raised and communicated to the administrator, but the available resources were insufficient to ensure privacy for all residents during personal care. The administrator and DNS both stated that the expectation was for privacy to be maintained at all times, but this was not achieved during the construction period.
Failure to Complete Required Employee Reference Checks During Hiring
Penalty
Summary
The facility failed to implement its abuse prevention policies and procedures regarding employee screening for three newly hired staff members. According to the facility's abuse policy, the screening process for potential employees requires contacting previous employers to obtain employment history, including dates of service, positions held, performance history, and any history of abuse or neglect. During a review of three randomly selected new hires, it was found that no reference checks were completed for these staff members. Both the Human Resources staff and the Administrator confirmed that reference checks had not been conducted for new hires since a change in facility ownership, despite the policy requirement.
Failure to Provide Sufficient Nursing Staff for Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the care needs of its residents, as evidenced by multiple documented instances of delayed response to call lights, unmet care needs, and insufficient staff coverage. Resident council notes and grievances indicated repeated concerns about excessive wait times for call light responses, sometimes exceeding one hour, particularly after 6:00 PM and during nighttime hours. Specific incidents included residents being left on the toilet for extended periods and not receiving pain medications in a timely manner. The facility's own records showed that on several dates, CNA staffing did not meet state minimum requirements, and there were days with no RN coverage. Interviews with residents confirmed these issues, with several residents reporting waits of up to an hour or more for assistance, especially during shift changes and nighttime. Residents also reported not being checked on regularly by staff. Staff interviews corroborated these concerns, with CNAs, LPNs, and CMAs describing frequent short staffing, high resident acuity, and an inability to complete care tasks or administer medications on time. Staff reported that management was aware of the staffing shortages, but concerns were not adequately addressed, and staff often had to forgo breaks or stay late to complete care. The facility's resident population included a significant number of individuals requiring assistance with activities of daily living, such as dressing, bathing, toileting, incontinence care, and two-person transfers, as well as residents with high acuity needs including wound care, tube feeding, and diabetic care. Staff reported that the high acuity and insufficient staffing made it difficult to provide timely and adequate care, particularly in specialized units such as memory care. Management acknowledged awareness of the staffing issues but indicated that additional staffing was contingent on census increases or further justification.
Failure to Complete Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to complete annual performance reviews for three certified nurse aides (CNAs) who had been employed for over one year. Documentation of annual performance reviews and hire dates was requested from the Director of Nursing Services (DNS) for these staff members, but no annual performance reviews were provided to the survey team. The DNS acknowledged that these CNAs had not received performance reviews in the past 12 months, despite being employed at the facility for more than a year.
Failure to Timely Obtain and Administer Routine Medications
Penalty
Summary
The facility failed to obtain and administer medications to residents in a timely manner, resulting in missed and delayed doses for multiple residents. For one resident with a history of alcohol dependence and osteoarthritis, a physician ordered trazodone for sleep, but the medication was not administered until five days after the order was written. Staff interviews revealed that the delay was due to the pharmacy not having the order and nursing staff not verifying or requesting the medication promptly. Additionally, the same resident experienced a lapse in receiving prescribed oxycodone for pain, with documentation showing the medication was unavailable for a day, and staff confirmed challenges in accessing the emergency medication system and obtaining necessary authorization codes from the pharmacy. A separate incident involved multiple residents receiving late or missed medications during a flooring renovation project. On the day of the project, residents were displaced from their rooms, and there was a shortage of staff, with only two nurses available and no certified medication aides. Staff reported difficulty accessing a working computer, which delayed the start of the morning medication pass until late morning. As a result, morning medications for several residents, including blood pressure medications, pain medications, antidepressants, diuretics, and anticoagulants, were administered several hours late or held entirely because it was too late to administer them per physician instructions. Facility records and staff interviews confirmed that these delays and omissions in medication administration were directly related to staff shortages, workflow disruptions due to the renovation, and communication issues with the pharmacy. The affected residents had various medical conditions, including pain, hypertension, diabetes, urinary retention, and depression, and were dependent on timely medication administration for their ongoing care.
Unattended and Unlocked Medication and Treatment Carts
Penalty
Summary
Facility staff failed to secure medications and biologicals as required by policy and professional standards. On two separate occasions, surveyors observed a treatment cart and a medication cart left unlocked and unattended in the hallway near the nurses station. The treatment cart contained resident insulin, creams, and other treatment supplies, while the medication cart contained resident medications. In both instances, the responsible LPNs acknowledged leaving the carts unlocked and unattended. The Director of Nursing Services confirmed that the facility's expectation was for all medication and treatment carts to be locked when unattended.
Multiple Infection Control Deficiencies Identified
Penalty
Summary
Staff failed to perform proper hand hygiene during meal service on two of three halls reviewed. Observations showed a CNA retrieving and delivering meal trays to multiple resident rooms without sanitizing hands between rooms or after handling soiled items such as used coffee cups. The CNA acknowledged not completing hand hygiene as required, and the Director of Nursing Services confirmed that staff were expected to sanitize hands before and after entering resident rooms and passing meal trays. The facility did not have a water management program or conduct a risk assessment for water-borne pathogens, including Legionella, as required by CMS guidelines. Review of facility policies indicated that an annual risk assessment and water management program were expected, but the facility assessment showed no evidence of such activities. The Maintenance Director and Administrator both confirmed that no water management program or prevention plan was in place for the facility's main water system. Staff did not follow CDC guidelines for Enhanced Barrier Precautions for two residents with indwelling catheters and other risk factors. Signage indicated that enhanced barrier precautions were in place, but used PPE was consistently disposed of in garbage bins located outside the residents' rooms rather than inside, as required. Multiple staff members confirmed this practice, and the Infection Preventionist acknowledged that used PPE should have been discarded inside the resident rooms.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform residents or their responsible parties about the risks and benefits of psychotropic medications and did not obtain consent prior to administration for two of five sampled residents. One resident, admitted with anxiety, was prescribed trazodone for a sleep disorder, but there was no documentation that the resident was informed of the medication's risks and benefits. Staff confirmed that this information was not provided. Another resident, admitted with anxiety and post-traumatic stress disorder, received quetiapine fumarate for anxiety without documentation of informed consent or evidence that the risks and benefits were discussed with the resident or their representative. The Director of Nursing Services confirmed that the medication was administered without obtaining consent.
Failure to Notify Physician of Critical Lab Result
Penalty
Summary
The facility failed to notify the ordering physician of a critical lab result for a resident with dementia who was admitted in 2024. On 10/9/24, laboratory tests revealed a critical hemoglobin level of 5.8 g/dL, which was reported to the facility the same day. The lab report indicated that a critical value was identified and the facility was contacted, but no staff were available to receive the result. The critical lab value remained unreviewed in the electronic health record due to a technical issue and a change in the phone system, and was not discovered by staff until 10/16/24. During this period, the resident developed abdominal pain, vomiting, and absent bowel tones, and was subsequently transported to the hospital. The delay in reviewing and communicating the critical lab result to the physician was confirmed through staff interviews and record review.
Failure to Obtain Resident Representative Consent for COVID-19 Vaccination
Penalty
Summary
The facility failed to obtain consent from the resident representative for the administration of a COVID-19 vaccine for one resident with severe cognitive impairment. The facility's policy required that residents be offered COVID-19 vaccinations upon admission and as eligible, with consent obtained prior to or at the time of vaccination. The resident in question had diagnoses including dementia and adult failure to thrive, and was identified as having severely impaired cognition on the most recent MDS assessment. The clinical record showed that the resident was educated about, offered, and refused the COVID-19 vaccine, but there was no documentation that the resident's Power of Attorney and healthcare decision maker was contacted for education or consent. Staff confirmed that the resident representative was not contacted regarding the vaccine.
Failure to Maintain Cleanliness and Safe Repairs in Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and well-repaired environment for two of three sampled residents. For one resident with hemiplegia, the shared bathroom was observed to have dried feces inside and outside the toilet bowl, with caked-on old feces between the bowl and tank, and feces splattered on the floor. Resident Council notes indicated ongoing issues with bathroom cleanliness and confusion among residents about which staff were responsible for cleaning. The resident and a family member confirmed the unsanitary condition had persisted for at least a day or two. The assigned housekeeping staff stated the bathroom was last cleaned the previous day but did not provide further explanation when shown the condition. The facility administrator acknowledged the bathroom was not clean at the time of observation. Additionally, the same resident's room had an electric outlet that was partially detached from the wall, exposing wires, with the resident's bed positioned in front of it and a device plugged in. Maintenance staff confirmed awareness of the issue, stating the outlet had been pulled from the wall for at least two months. Another resident's room was found to have a window with a large piece of bottom trim missing, leaving jagged edges exposed. Maintenance staff acknowledged the missing trim and exposed edges.
Failure to Develop Person-Centered Bowel Care Plan
Penalty
Summary
The facility failed to develop a person-centered, comprehensive care plan that addressed a resident's specific preferences for bowel care. The resident, who has quadriplegia and is incontinent of bowel, was identified as being at risk for constipation and had a care plan that included a bowel regimen with medications and suppositories. However, the care plan did not specify the resident's preference for receiving a suppository before oral medications, despite this being a long-standing request. Multiple staff interviews confirmed that the resident preferred suppositories over oral medications and would become upset when this preference was not honored, particularly by agency staff who were unaware of the resident's wishes. The lack of documentation regarding the resident's bowel care preferences led to inconsistent care delivery, with agency staff administering oral medications instead of suppositories, contrary to the resident's expressed wishes. The resident's care plan was not updated to reflect these preferences, and staff acknowledged that this omission contributed to the resident's dissatisfaction and distress during care. The deficiency was identified through interviews with the resident and staff, as well as a review of the care plan and medical records.
Failure to Clarify Medication Orders Leads to Prolonged Medication Error
Penalty
Summary
Staff failed to adhere to professional standards for medication management when a resident with schizophrenia and major depressive disorder was involved in a medication error. The resident had been receiving escitalopram (Lexapro) 20 mg daily as documented in the medication administration record (MAR). On 3/4/24, a provider note indicated a plan to halve the dose of Celexa (citalopram), but the resident had not previously been on Celexa. The new order for Celexa 10 mg daily was transcribed by an LPN, and escitalopram was discontinued with the reason documented as a decrease to 10 mg. As a result, the resident received Celexa 10 mg daily for 25 days in error, due to a discrepancy between the provider order and the resident’s actual medication history. Nursing staff did not clarify the physician order, and the error was not identified until a psychotropic drug review.
Failure to Clarify and Administer Medications as Ordered
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and residents' needs for three residents. For one resident with congestive heart failure, the care plan required daily monitoring of bowel movements and administration of Milk of Magnesia if no bowel movement occurred after three days. However, records showed two separate four-day periods without a bowel movement, during which no bowel medication was administered or documented as offered, accepted, or refused. Staff interviews confirmed that monitoring and documentation were lacking, and the care plan did not reflect the resident's history of refusing bowel medication. Another resident with diabetes was admitted with a new sliding scale insulin order that required staff to administer insulin and contact the physician if the capillary blood glucose (CBG) exceeded 300. The resident had a CBG of 327, but there was no documentation that insulin was given or that the physician was contacted to clarify the order or report the elevated CBG. The Director of Nursing Services acknowledged that the order was not clarified and the required actions were not taken. A third resident with schizophrenia and major depressive disorder experienced a medication discrepancy involving antidepressants. The provider ordered a dose reduction of citalopram (Celexa), but the resident had not previously been receiving this medication. Instead, the resident was on escitalopram (Lexapro), which was discontinued and replaced with citalopram per the new order. The resident received citalopram in error for 25 days due to a failure to clarify the provider's order, and the discrepancy was not identified until a psychotropic drug review. Staff interviews confirmed the error and lack of order clarification.
Failure to Complete Fall Assessment After Resident Fall
Penalty
Summary
The facility failed to complete a fall assessment for a resident with dementia who experienced an unwitnessed fall. On the date of the incident, a CNA reported the fall to the nurse, who then took the resident's vital signs, assessed for injuries, and initiated neuro checks. The resident was found to be confused but had intact skin and no immediate signs of bruising or injury. Despite these actions, a formal fall assessment was not completed for the incident, as confirmed by the Director of Nursing Services when requested at a later date.
Delay in Diagnostic Lab Services Due to Specimen Labeling Error
Penalty
Summary
The facility failed to provide timely diagnostic services for a resident with diabetes who was admitted in 2024. A physician order was received on 10/3/24 to obtain a stool sample to rule out Clostridium Difficile (c-diff). Staff initially collected the sample after the order was received, but mistakenly labeled it with another resident's name. As a result of this error, staff had to collect a new sample on 10/9/24, which delayed the laboratory results. The Director of Nursing Services confirmed that the order was not completed until 10/9/24, several days after the initial request.
Failure to Administer Pneumococcal Vaccine After Obtaining Consent
Penalty
Summary
The facility failed to administer a pneumococcal vaccine to one of five sampled residents who was reviewed for immunizations. The resident, admitted with diagnoses including diabetes and heart failure, was found to be cognitively intact according to the most recent MDS assessment. The clinical record showed an undated pending consent for the Prevnar 20 pneumococcal vaccine. The Infection Preventionist reported that she had educated and offered the vaccine to the resident, who gave verbal consent, but did not follow up, resulting in the vaccine not being administered.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate and complete daily nurse staffing information as required. A review of the Direct Care Staff Daily Reports over a period from January 1, 2025, through March 18, 2025, showed that on five separate days, portions of the required forms were either left blank or contained inaccurate information. The missing or incorrect data included the daily census and the number of working staff. This deficiency was confirmed by the facility administrator, who acknowledged the incomplete and inaccurate reports for the identified dates. No specific residents or their medical conditions were mentioned in relation to this deficiency.
Failure to Prevent Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident, resulting in a serious injury. Resident 13, who has Alzheimer's and paranoid schizophrenia, deliberately kicked Resident 14's walker, causing Resident 14 to fall and sustain a head laceration, contusion, and a fractured hip requiring surgery. This incident occurred while Resident 13 was visiting with a family member in the hallway, and no staff were present during the altercation. Resident 13 had a history of moderate cognitive impairment and behaviors such as agitation and suspiciousness, while Resident 14 had severe cognitive impairment and was known for physical and verbal aggression. Despite these known behaviors, the facility did not adequately monitor or separate the residents, leading to the altercation. Previous incidents between the two residents had occurred, including a physical altercation on a prior date, but interventions to prevent further incidents were insufficient. Staff members were not fully aware of the need to monitor or separate the residents, and there was a lack of communication regarding the residents' behaviors and necessary precautions. The facility's failure to supervise and protect the residents resulted in a preventable injury, highlighting a deficiency in the facility's ability to ensure resident safety and prevent abuse.
Failure to Notify Resident and Family of Room Change
Penalty
Summary
The facility failed to provide advance written notice to a resident or their responsible party prior to a room change, violating the resident's rights. Resident 10, who was admitted with diagnoses including dementia and visual disturbances and was receiving hospice services, was moved from room 17-2 to 21-2 without prior notification to the resident or their family. The resident's spouse, who was the responsible party, discovered the room change upon visiting and noted that the resident's behavior became more anxious and aggressive following the move. The facility's administrator confirmed that no notification was made to the resident or family before the room change, and there was no documentation in the resident's clinical record regarding the notification of the room move.
Failure to Follow Transfer Protocols Resulting in Resident Injury
Penalty
Summary
The facility failed to adhere to care plan interventions for a resident requiring two-person assistance with a gait belt for transfers, leading to a potential risk of injury. The resident, admitted in March 2019 with diagnoses including spinal fusion and anxiety, was cognitively intact with a BIMs score of 15. On August 3, 2024, an agency CNA attempted to transfer the resident without a second staff member, contrary to the care plan. The CNA reported that the resident claimed to be a one-person stand and pivot transfer, but the transfer was unsuccessful, and the resident was returned to bed. The resident later reported being dropped on the floor, complained of pain, and was unable to lay flat, leading to a hospital transfer where a distal femur fracture was diagnosed. Hospital records did not indicate the cause of the fracture, and attempts to contact the CNA for further information were unsuccessful. An LPN confirmed the resident was not transferred correctly but could not confirm the cause of the fracture.
Resident Abuse Incident During Activity
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal and physical abuse by another resident. Resident 3, who was admitted to the facility in 2024 with a diagnosis of obesity, was verbally and physically abused by Resident 4 during a bingo activity. Resident 4, who was also admitted in 2024 and had a diagnosis of dementia with behaviors, became agitated and kicked Resident 3 in the left foot three times while yelling profanities. This incident was documented in a facility Event Summary Report dated 1/30/24, which confirmed the verbal and physical abuse by Resident 4 toward Resident 3. Resident 3 reported feeling both physically and verbally abused, stating that Resident 4 kicked them multiple times and used derogatory language, including calling them a 'fat [expletive]'. Resident 3 also mentioned having a small bruise from the incident. Despite forgiving Resident 4, Resident 3 expressed that they could not forget the event. Resident 4, who was often confused and cognitively impaired, was unable to recall the incident. The facility's administrator and DNS acknowledged the findings of abuse related to this incident.
Latest citations in Oregon
A resident with acute respiratory failure and heart failure had a documented Full Code status and a POLST specifying Attempt Resuscitation/CPR and Full Treatment. During night rounds, two CNAs found the resident not breathing, cool to the touch, with yellow skin and no pulse, but did not initiate CPR or call a code blue, instead going to notify an LPN. The LPN assessed the resident, confirmed absence of vital signs, noted the body was cold with mottling and no rigor mortis, and contacted the DNS, physician, and 911 for the coroner’s number, but did not start CPR or activate a code blue. No lifesaving measures were attempted despite facility policy requiring CPR for unresponsive residents without a valid DNR and the resident’s clearly documented full code status, leading surveyors to cite Immediate Jeopardy and substandard quality of care.
A resident with respiratory failure and pneumonia, who was Full Code and not on hospice, was found during routine rounds and suspected to be deceased. Nursing staff assessed the resident, noted there was no rigor mortis, confirmed death, and did not initiate a code blue or any resuscitation efforts despite the resident’s Full Code status. The facility later treated this as a potential neglect incident but did not report it to the State Agency within the required two-hour timeframe, as confirmed by the regional QA director.
A resident with chronic pain and a left below-knee amputation, who required supervision or touching assistance with ADLs, was discharged after returning from an outing shortly after midnight. Although discharge instructions noted the need for assistance and assistive devices, there was no documentation of referrals for medical equipment or home health services. Facility staff documented that the resident was discharged because they were out past midnight and believed Medicare would not cover the stay, did not issue a NOMNC, and recorded the discharge as voluntary despite the resident later reporting they had been “kicked out” and were sleeping on a friend’s couch with difficulty getting around. Staff interviews revealed no financial issues and indicated the resident had originally been scheduled for discharge at a later date.
A resident with a hip fracture and anxiety reported to social services that a CNA had been rough, told the resident to take themself to the bathroom, and instructed them not to get out of bed until a specified early morning time. The allegation was received by facility staff in the late afternoon, but the incident report was not submitted to the State Agency until the following day, exceeding the required 2-hour reporting timeframe acknowledged by the DNS. The deficiency concerns this untimely reporting of an abuse allegation, despite the CNA’s denial of any abuse.
A resident with hemiplegia, previously evaluated as not appropriate to self-administer any medications, was found to have open tubes of antifungal cream, anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) stored in a bedside drawer. Record review showed there were no MD orders for several of these topical products and no order permitting self-administration. An RN case manager confirmed the absence of orders, and the resident reported self-administering the medications, demonstrating a failure to ensure medications were administered only as ordered and in accordance with the resident’s assessed ability.
A resident with hemiplegia, previously evaluated as not appropriate to self-administer medications, was found with open containers of anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) in a bedside drawer. Record review showed no MD orders, no documented indication for use, and no monitoring for these medications. An RN case manager confirmed there were no orders and that staff did not administer or monitor the creams, while the resident reported self-administering them.
The facility failed to investigate multiple staff-reported allegations that one cognitively intact, wheelchair-using resident engaged in sexually inappropriate behaviors toward three other residents with significant cognitive and neurological impairments. Staff reported finding a resident with a ripped brief, crying and resisting care, and suspected sexual contact; they also reported that the alleged aggressor tried to take another resident into a shower room for sexual acts, attempted to video and kiss that resident, and encouraged a third resident to remove their top while present with a phone. CNAs, social services, and other staff stated they informed the administrator, DNS, HR, and unit management about these incidents and behaviors, but the administrator acknowledged that no investigations were conducted, despite being aware of the reports.
A resident with multiple sclerosis, care planned as dependent on two staff and requiring a Hoyer lift for transfers, was instead transferred by a CNA using a stand-pivot method without the lift or a second staff member. The CNA reported she had not read the resident’s care plan and described performing the transfer by giving the resident a “giant bear hug” and making several attempts to move the resident from chair to bed. The resident reported right flank pain and stated the transfer caused three broken ribs, although an x-ray later showed no rib fractures or dislocation and no visible injury was noted.
A resident with multiple sclerosis was admitted with physician orders for PT and OT, but review of the clinical record showed no documentation that these therapies were ever provided. The resident reported not receiving any therapy since admission, and the Director of Rehabilitation confirmed that no therapy services had been delivered during this period despite active orders, resulting in a failure to provide ordered rehabilitative services.
A dependent resident with dementia and a history of stroke, identified on the MDS as requiring staff assistance for showers, did not consistently receive scheduled bathing, and one CNA falsely documented that bathing had been provided. CNA task reports showed missed or undocumented baths on scheduled days, and an internal investigation confirmed that a bath recorded as completed on one date had not actually occurred. Staff interviews indicated that if bathing was not documented it usually did not occur, and that scheduled bathing was expected to be provided by staff.
Failure to Initiate CPR for a Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide CPR in accordance with a resident’s documented full code status. The facility’s Emergency Procedure CPR policy, initiated in 2001, required staff trained in CPR to initiate resuscitation on unresponsive residents who were not breathing unless there was a valid DNR order or clear signs of irreversible death such as rigor mortis. The policy further specified that if a resident’s DNR status was unclear, CPR should be started and continued until a DNR was confirmed. Resident 3 had been admitted with diagnoses including acute respiratory failure and heart failure and had a care plan and POLST on file indicating Full Code/Attempt Resuscitation and Full Treatment, including use of intubation, advanced airway interventions, mechanical ventilation, and transfer to hospital or ICU if indicated. On the night of the incident, a CNA (Staff 5) documented last vital signs for the resident at approximately 10:45 PM, with oxygen saturation of 92% on one liter of oxygen. At 2:00 AM, the resident was observed sleeping, breathing, and with a dry brief. Around 4:00 AM, Staff 5 and another CNA (Staff 8) entered the resident’s room and observed that the resident was not breathing, had yellow skin color, was cool to the touch, and had no palpable pulse. Both CNAs concluded the resident was deceased and went to notify the LPN (Staff 4) instead of initiating CPR or calling a code blue, despite having recent CPR training and later stating that, in retrospect, they would have started CPR and called for a code blue. When Staff 4 (LPN) entered the room, she assessed the resident and found no pulse, blood pressure, or respirations, noted the body was cold, with some mottling on the lower legs, pale/yellowish skin color, and no rigor mortis. Staff 4 did not initiate a code blue or CPR and instead contacted the DNS (Staff 2) and the physician, and then called 911 to obtain the coroner’s phone number. No lifesaving measures were attempted by any staff, despite the resident’s documented full code status and the facility policy requiring CPR in the absence of a valid DNR or signs of irreversible death. The DNS later stated she expected staff to call a code blue immediately, start CPR, call 911, and verify the resident’s code status. Surveyors determined that the facility failed to provide CPR according to the resident’s code status, placing all residents with full code status at risk and constituting substandard quality of care, with the noncompliance cited as Immediate Jeopardy and Past Noncompliance.
Removal Plan
- Administrator, DNS and nursing staff would be re-educated on the code blue process, how to locate a resident's code status in PCC and the POLST on file, and the importance of following individual resident care plans and orders.
- Resident code status would be cross-referenced with the PCC order, POLST scanned in binder, care plan, and resident dashboard.
- DNS or designee would monitor resident code status preferences for new admissions/returning admissions from hospitalizations.
- DNS or designee would audit code status for all new admissions and readmissions from hospitalization or ED visits, and share audit results with the QAPI committee to ensure substantial compliance is maintained.
- DNS or designee would complete a mock code.
- DNS or designee would complete mock codes.
Failure to Timely Report Alleged Neglect Involving Lack of CPR for Full Code Resident
Penalty
Summary
The facility failed to timely report an allegation of potential neglect related to CPR to the State Agency for one resident. The resident was admitted in February 2026 with diagnoses including respiratory failure and pneumonia and had a Full Code status, was not on hospice, and therefore was to receive CPR if found unresponsive. According to the facility’s investigation dated six days after the resident’s death, staff found the resident during routine rounds and suspected the resident was deceased, notified the nurse, and the nurse confirmed the resident was deceased. The investigation documented that at the time of the nurse’s assessment the resident did not have rigor mortis, yet the nurse did not initiate a code blue or any resuscitation interventions despite the Full Code status. The incident, which occurred on an identified date, was not reported to the State Agency until a later identified date, and the Regional Director of Quality Assurance confirmed that the facility did not report the incident within the required two-hour timeline. This failure to timely report the allegation of potential neglect involving the lack of CPR initiation for a Full Code resident constituted the deficiency identified by surveyors.
Failure to Ensure Safe and Orderly Discharge After Late Return from Outing
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and orderly discharge for a resident who was admitted with chronic pain, a left below-knee amputation, and post-surgical aftercare needs. An admission MDS completed shortly after admission documented that the resident was cognitively intact but required supervision or touching assistance with toileting, transfers, and bathing. Discharge instructions indicated the resident was being discharged home and that the resident’s current physical status required assistance and assistive devices, yet there was no documentation of referrals for needed medical equipment or a home health referral. The facility’s records did not show that these services or equipment were arranged prior to discharge. On the night in question, a nursing note documented that the resident returned to the facility after an outing at 12:23 AM, after the facility had notified the police because the resident’s location was unknown. The resident reported having been out with friends and being unaware of any concern. A social services note stated that because the resident was out past midnight, the resident was discharged from the facility, and a NOMNC was not issued because the resident left prior to the scheduled discharge and on their own initiative. A discharge summary documented that discharge instructions were reviewed with the resident, who refused to sign and was leaving voluntarily, and the voluntary consent form included a handwritten statement that the resident refused to sign. Later, the resident stated they had been “kicked out” for coming back late and were sleeping on a friend’s couch, finding it difficult to get around. Staff interviews showed there were no financial issues documented, that staff believed Medicare would not cover the resident if out past midnight, and that the resident had been scheduled for discharge several days later, while a regional director later characterized the situation as a clerical error and confirmed a normal discharge should have been completed.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to timely report an allegation of abuse to the State Agency after a resident reported that a CNA had been rough and verbally directive with them. The resident, who had been admitted with diagnoses including a hip fracture and anxiety, stated that the CNA was “kind of rough,” told the resident to take themself to the bathroom, and instructed the resident not to get out of bed until 6:00 AM. The resident reported this allegation of abuse involving the CNA to the social services staff member at 4:00 PM on 1/29/26. According to the facility’s investigation documentation, the allegation was received by staff at 4:00 PM on 1/29/26, and the Facility Reported Incident form was not received by the State Agency until 2:13 PM on 1/30/26. The DNS acknowledged that the facility became aware of the allegation at 4:00 PM on 1/29/26 and that it should have been reported to the State Agency within two hours but was not. The CNA denied abusing the resident or any resident, but the deficiency centers on the delay in reporting the allegation to the State Agency within the required timeframe.
Failure to Prevent Unauthorized Self-Administration of Non-Prescribed Medications
Penalty
Summary
Surveyors identified that a resident was self-administering non-prescribed topical medications despite a documented determination that they were not appropriate to self-administer any medications. The resident, admitted with hemiplegia, had a Self-Medication Administration Evaluation dated 11/13/25 indicating they were not appropriate to self-administer medications. During an observation on 3/19/26 at 7:50 AM with a RN case manager, open tubes of antifungal cream, anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) were found in the resident’s bedside table drawer. Review of the clinical record showed there were no physician orders for the anti-itch cream, hydrocortisone cream, or DMSO, and the resident did not have an order to self-administer any medications. The RN case manager confirmed the lack of orders for these medications, and at 8:10 AM the resident stated they did self-administer the medications found in their room. This constituted a failure by the facility to ensure the resident did not self-administer non-prescribed medications and to provide treatment and care according to physician orders and the resident’s evaluated ability to self-administer medications.
Unmonitored Self-Administration of Topical Medications Without Physician Orders
Penalty
Summary
The facility failed to ensure a resident’s drug regimen was free from unnecessary drugs by not providing adequate monitoring, indication for use, or physician orders for multiple medications. A resident admitted with hemiplegia in May 2024 had a self-medication administration evaluation dated 11/13/25 indicating they were not appropriate to self-administer any medications. During an observation on 3/19/26, an RN case manager found an open tube of anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) in the resident’s bedside table drawer. Record review showed no physician orders, no documented indication for use, and no monitoring for these medications. The RN case manager confirmed the resident did not have orders for the anti-itch cream, hydrocortisone cream, or DMSO, and that staff did not administer or monitor these medications. The resident stated they self-administered the medications found in their room, despite the prior evaluation determining they were not appropriate to self-administer any medications.
Failure to Investigate Multiple Allegations of Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to investigate multiple allegations of sexual abuse involving three residents. Resident 102, who had cognitive loss equivalent to a young child, legal blindness, and was non-verbal, was reportedly found with a ripped brief, crying, and resisting a brief change. Staff reported concerns that another resident, Resident 105, had performed or attempted to perform sexual acts on Resident 102. Staff members, including CNAs and social services, stated they informed facility management, including the Administrator and DNS, about the torn brief, Resident 102’s distress, and concerns that Resident 105 was being sexually inappropriate with multiple residents. Despite these reports and discussions in morning meetings, the Administrator acknowledged that no investigation was completed, believing the incident was based on staff assumptions. The facility also failed to investigate allegations involving Resident 103, who had Alzheimer’s disease and Parkinson’s disease. Staff reported that Resident 105 attempted to take Resident 103 into a shower room to perform sexual acts, and that a staff member intervened. The complainant later spoke with Resident 103, who stated that Resident 105 was “sick” and made bad comments. Other staff reported to human resources, the DNS, and the Administrator that Resident 105 attempted to take a resident into a shower room to unclothe the resident, and that Resident 105 attempted to video Resident 103, expressed a desire to kiss Resident 103, and get the resident into a shower room. The Social Service Director confirmed she reported these concerns to the Administrator, who stated he was aware of the incident but that no investigation was completed. A third failure to investigate involved Resident 108, who had Huntington’s disease and dementia. A staff member reported observing Resident 105 telling Resident 108 to take off their shirt and gesturing for them to do so, and stated they completed a written statement and gave it to the unit manager. Another CNA reported hearing that Resident 105 and other residents were laughing and encouraging Resident 108 to remove their top, and also reported observing Resident 105 rubbing other residents’ backs more physically than appropriate. Social services reported being told that Resident 108 was removing their top while Resident 105 was in the dining room with a phone, and that Resident 105 admitted to the behavior but described it as innocent. The Administrator stated he was aware of Resident 108 removing their shirt while Resident 105 was present, yet confirmed that no investigation was completed for this incident. These failures to investigate led surveyors to determine that the facility did not respond appropriately to alleged violations of sexual abuse for the three residents.
Removal Plan
- Residents 102, 103, and 108 received head-to-toe skin assessments completed by RCMs with no observed findings.
- Resident 105 was placed on one-to-one observations pending investigations.
- Staff 1 (Administrator) and Staff 2 (DNS) were re-educated on the facility's abuse policy, reporting, and thorough investigations.
- Social Services will interview all interviewable residents regarding abuse.
- Nurses will complete a head-to-toe assessment on all non-interviewable residents.
- All staff, including agency staff, will be re-educated on the facility's abuse policy and reporting.
Failure to Follow Care-Planned Hoyer Lift Transfer Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow a resident’s care plan interventions for transfers, resulting in a transfer being performed without required equipment and assistance. A resident admitted in February 2026 with multiple sclerosis had a 2/25/26 ADL care plan indicating the resident was dependent on two staff members for transfers and required use of a Hoyer (mechanical) lift. Despite this, on 2/28/26 a CNA (Staff 3) performed a stand-pivot transfer without the Hoyer lift and without a second staff member. The resident later reported that Staff 3 gave a “giant bear hug” and made several attempts to transfer the resident from chair to bed, after which the resident reported right flank pain and stated the transfer caused three broken ribs. An x-ray on 3/10/26 showed no rib fractures or dislocation, and the resident was assessed to have no visible injury. During interview, Staff 3 confirmed she had completed a stand-pivot transfer with the resident and acknowledged she had not read the resident’s care plan, and the Administrator confirmed that the resident had been care planned for a two-person Hoyer lift transfer at the time of the incident.
Failure to Provide Ordered Rehabilitative Services
Penalty
Summary
The facility failed to provide ordered rehabilitative services to a resident with multiple sclerosis. The resident was admitted in February 2026 with admission orders dated 2/24/26 for both physical therapy and occupational therapy. Review of the resident’s clinical record showed no documented evidence that any therapy services were provided as ordered. In an interview on 3/11/26 at 10:58 AM, the resident reported not having received any therapy since admission. During a separate interview on 3/11/26 at 10:40 AM, the Director of Rehabilitation confirmed that the resident had not received any therapy services from the date of admission through 3/11/26, despite the existing orders for physical and occupational therapy. This failure to implement the physician’s orders for rehabilitative services for this resident placed the resident at risk for a decline in range of motion.
Failure to Provide and Accurately Document Scheduled Bathing for a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a dependent resident received required assistance with activities of daily living (ADLs), specifically bathing, and inaccurate documentation that bathing had been provided. The resident, admitted in 10/2025 with dementia and stroke, had a 10/21/25 admission MDS indicating severe cognitive impairment and dependence on staff for showers. The facility’s 12/2025 CNA task report showed the resident was scheduled for bathing on day shift on Wednesdays and Sundays. On 12/24/25, the task report was blank for bathing, and on 12/28/25, the report documented that the resident received bathing and was dependent on staff for assistance. However, a 12/29/25 facility investigation determined the resident did not receive a bath on 12/28/25 and that it had been falsely documented that bathing occurred. A Facility Reported Incident form dated 12/31/25 further documented that on 12/28/25, a CNA (Staff 5) noted providing bathing to the resident but did not provide any type of bathing. Additional record review showed that the resident’s 3/2026 CNA task report contained no documentation that any type of bathing was provided on 3/11/26. Attempts to contact Staff 5 on 3/16/26 and 3/17/26 were unsuccessful. During interviews, another CNA (Staff 7) stated that on 12/28/25 she observed Staff 5 lay the resident down and, when she asked about bathing, Staff 5 said she would complete the resident’s bathing in the evening; Staff 7 stated she could not perform the resident’s bathing in the evening because she moved to a different hall on evening shift. Another CNA (Staff 21) stated that usually if bathing was not documented in the resident’s record, bathing did not occur. The Regional Nurse (Staff 31) stated that staff should provide scheduled bathing to residents.
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