Columbia Basin Care Facility
Inspection history, citations, penalties and survey trends for this long-term care facility in The Dalles, Oregon.
- Location
- 1015 Webber Street, The Dalles, Oregon 97058
- CMS Provider Number
- 385049
- Inspections on file
- 19
- Latest survey
- February 2, 2026
- Citations (last 12 mo.)
- 12 (1 serious)
Citation history
Health deficiencies cited at Columbia Basin Care Facility during CMS and state inspections, most recent first.
The facility failed to store and handle food properly, risking cross-contamination. Raw meat was stored above eggs, and scoops were improperly placed in food bins. A dietary cook used the same gloves for different tasks without changing them, and unlabeled drinks were found in a refrigerator, violating food safety protocols.
A Gerontology Nurse Practitioner failed to adequately document the evaluation of care for three residents with chronic conditions during scheduled visits. The documentation lacked evidence of comprehensive assessments, and the practitioner was unsure of where the records were stored in the electronic health system. The facility's administration acknowledged the notes were not comprehensive.
The facility did not ensure accurate Direct Care Staff Daily Report (DCSDR) postings for 16 out of 27 days, leading to potential misinformation for residents and visitors. The Staffing Coordinator admitted to not understanding how to complete the DCSDR and failed to update it with schedule changes, while the Administrator expected accuracy in these reports.
The facility failed to implement Enhanced Barrier Precautions and ensure proper PPE use for residents, leading to potential infection risks. A resident with pneumonia had inconsistent PPE use by staff, while another with a leg wound did not have staff wearing gowns during care. Additionally, improper PPE disposal and lack of precautions for a resident with a catheter were observed, indicating systemic issues in infection control protocols.
A resident with severe cognitive impairment was physically abused by another resident with moderate cognitive impairment and a history of behavioral issues. The incident occurred when the aggressive resident, confused and agitated, believed their wheelchair was being interfered with and responded by hitting the other resident. Staff noted the aggressive resident's pattern of anger and witnessed the altercation, which resulted in a small injury to the victim.
A facility failed to maintain a resident's wheelchair in good repair, resulting in torn and cracked armrests with sharp edges. The resident, who used the wheelchair daily, found the armrests uncomfortable. Despite protocols for reporting and inspecting equipment, staff did not notice or report the disrepair.
A facility failed to conduct a significant change MDS assessment for a resident who experienced a seizure, cognitive decline, and behavioral issues. Despite these changes, no assessment was documented, and staff confirmed the oversight.
A facility failed to complete a PASARR I screening before admitting a resident with multiple sclerosis and major depressive disorder. The resident, who required substantial assistance with ADLs, was admitted without the necessary screening, which was not added to their health record even after a month. This oversight risked inappropriate placement and lack of needed services.
A resident without a documented history of epilepsy was prescribed an anticonvulsant after experiencing seizures following the administration of an antipsychotic. The facility's records did not reflect a seizure disorder diagnosis, and staff interviews revealed uncertainty about the cause of the seizures, suggesting potential links to recent infections. The facility acknowledged a lapse in consulting with a physician regarding the epilepsy diagnosis.
A resident with a self-care deficit due to a stroke and chronic pain did not receive necessary assistance with ADLs, as documented in their care plan. Observations showed a persistent brown stain on the resident's face, which staff confirmed. The facility's leadership acknowledged the expectation for staff to clean the resident's face, highlighting a failure to meet the resident's care needs.
A resident with a history of falls and multiple diagnoses, including dementia, was not provided with a fall mat as required by their care plan. Despite the care plan's directive, observations showed the mat was missing, and staff were unaware of this requirement. This oversight placed the resident at risk for injury.
A facility failed to obtain a physician order and provide timely PICC dressing care for a resident admitted with a lung abscess and pneumonia. The resident's PICC dressing was not changed for 12 days, contrary to the facility's protocol requiring changes every seven days. A nurse confirmed the oversight and lack of documentation.
A facility failed to ensure a resident, admitted with a stroke and chronic pain, was seen by a physician. A review of the resident's clinical record showed no documented physician visits since admission, confirmed by the Administrator and Social Services Supervisor.
A resident admitted with a pelvis fracture did not receive prescribed medications for five days due to unavailability. The CMA did not contact the pharmacy or notify the physician, and the RNCM was unaware of the issue, expecting staff to address medication unavailability within one day.
A facility did not follow pharmacy recommendations for a resident's trazodone prescription, which was intended to treat insomnia. The pharmacist advised separating the scheduled and PRN portions of the order for proper charting, but the June and July MARs showed the order continued unchanged. The recommendations were not fully implemented until mid-July.
A facility failed to monitor psychotropic medications for a resident, risking ineffective medication management. The resident, with insomnia, depression, and pain, was prescribed fluoxetine, trazodone, and olanzapine. The care plan required monitoring side effects and effectiveness every shift, but no documentation was found. Staff noted that a system switch led to the omission of monitoring, which was not corrected despite management being informed. This was confirmed by the administrator and social services supervisor.
Food Storage and Handling Deficiencies
Penalty
Summary
The facility failed to store and handle food properly, leading to potential cross-contamination risks. During an inspection, raw meat was found stored on a wire rack shelf directly above eggs and cartons of liquid whole eggs in the walk-in refrigerator, which could lead to dripping and contamination. Additionally, plastic-handled scoops were stored in direct contact with food items such as brown sugar, powdered sugar, white sugar, and dry pasta, increasing the risk of cross-contamination. The Food Service Director acknowledged these issues, attributing them to staff negligence. Further observations revealed improper food handling practices by staff. A dietary cook used the same gloved hand to open an oven door and then handle a dinner roll, which was placed on a resident's lunch plate without changing gloves, creating an opportunity for cross-contamination. Additionally, two unlabeled plastic mugs containing a brown thickened liquid were found in a snack refrigerator, lacking proper labeling and dating as required by the US FDA 2022 Food Code. The Food Service Director was unaware of who placed the mugs in the refrigerator, highlighting a lapse in adherence to food safety protocols.
Inadequate Documentation of Resident Care by Provider
Penalty
Summary
The facility failed to ensure that the total program of care for three residents was adequately reviewed and documented during provider visits. Resident 4, who was admitted in 2020 with a diagnosis of neuralgia, had provider visits in March, May, and July 2024 conducted by a Gerontology Nurse Practitioner, Staff 29. However, the documentation from these visits lacked sufficient evidence that the resident's condition and total program of care were evaluated. Staff 29 admitted uncertainty about where the documentation was recorded in the electronic health record and could not provide additional information regarding her evaluations. Similarly, Resident 21, admitted in February 2023 with chronic pain and dementia, and Resident 23, admitted in May 2019 with dementia and hypertension, also had provider visit notes that were insufficient in documenting evaluations of their conditions and total programs of care. Staff 29 conducted these visits but again failed to provide comprehensive documentation. The facility's Administrator and Director of Nursing Services reviewed the notes and acknowledged that they were not comprehensive, indicating a systemic issue with documentation during provider visits.
Inaccurate Staffing Reports
Penalty
Summary
The facility failed to ensure the accuracy of the Direct Care Staff Daily Report (DCSDR) postings for 16 out of 27 days reviewed, which could lead to residents and visitors receiving inaccurate staffing information. The review of the DCSDR from August 1 to August 27, 2024, revealed discrepancies in the reported hours worked by Certified Nursing Assistants (CNAs) and Nursing Assistants (NAs) on specific dates. On August 29, 2024, the Staffing Coordinator (Staff 17) admitted to not fully understanding how to complete the DCSDR and failing to update the report to reflect schedule changes. The Administrator (Staff 1) expected the DCSDR to be accurate, indicating a lack of proper training or oversight in maintaining accurate staffing records.
Failure to Implement Enhanced Barrier Precautions and PPE Use
Penalty
Summary
The facility failed to implement appropriate Enhanced Barrier Precautions (EBP) and ensure the correct use of personal protective equipment (PPE) for three residents, leading to a risk of infection spread. Resident 146, admitted with an abscess of the lung and pneumonia, had Contact Precautions signage posted, but staff were observed entering the room without donning PPE. Staff expressed confusion about the required precautions, and the resident confirmed inconsistent PPE use by staff. Similarly, Resident 43, with an infected leg wound, did not have staff consistently wearing gowns during wound care, despite the presence of PPE containers outside the room. The Infection Preventionist was unaware of the gown requirement for EBP, indicating a lack of proper training and communication. Additionally, the facility's infection control practices were inadequate, as observed with the improper disposal of used PPE and the absence of a disposal container in one room. Resident 296, with an indwelling catheter, was not placed on EBP, contrary to the requirements. Staff confirmed the oversight, highlighting a systemic issue in the facility's infection control protocols. These deficiencies demonstrate a failure to adhere to established guidelines for preventing infection transmission, putting residents at risk.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse, as evidenced by an incident involving two residents. Resident 16, who was admitted with a severe cognitive impairment, was physically abused by Resident 13, who has moderate cognitive impairment and a history of behavioral issues. On the day of the incident, Resident 13, who was confused and agitated, believed that Resident 16 was interfering with their wheelchair and responded by hitting Resident 16 in the face, causing a small open area. Staff members witnessed the altercation and noted that Resident 13 was having a particularly bad day, exhibiting aggressive behavior towards both residents and staff. Interviews with staff and residents revealed that Resident 13 had a pattern of becoming angry without apparent reason, and on this occasion, they verbally and physically lashed out. Despite the incident, Resident 16 later reported feeling safe in the facility, although initially uncomfortable around Resident 13. The facility's investigation confirmed the altercation and the inappropriate behavior of Resident 13, highlighting a failure to adequately protect Resident 16 from abuse.
Failure to Maintain Resident Care Equipment
Penalty
Summary
The facility failed to ensure that resident care equipment was in good repair, specifically for a resident with multiple sclerosis who was cognitively intact and used a wheelchair. Observations over several days revealed that the resident's wheelchair had torn and cracked vinyl coverings on both armrests, with sharp, rough edges protruding. The resident reported using the wheelchair daily and described the armrests as uncomfortable and rough on their skin. Despite the facility's protocol for staff to report equipment in disrepair to maintenance and conduct nightly wheelchair inspections, the issues with the wheelchair were not noticed or reported by the staff responsible for the resident's care.
Failure to Conduct Significant Change MDS Assessment
Penalty
Summary
The facility failed to document and conduct a significant change Minimum Data Set (MDS) assessment for a resident who experienced notable changes in condition. The resident was admitted with diagnoses including stroke and depression and initially assessed as cognitively intact with a BIMS score of 14. Over time, the resident's condition changed significantly, including a seizure event and a new prescription for topiramate for epilepsy. Additionally, the resident was involved in a physical altercation with another resident and exhibited behavioral changes, such as increased cognitive impairment and incontinence, as noted in a subsequent quarterly MDS. Despite these significant changes, no significant change assessment was found in the resident's clinical record. Interviews with staff revealed that the resident exhibited behaviors such as verbal abuse and physical aggression, particularly after family visits. The facility's administrator and interim Director of Nursing Services confirmed that a significant change MDS should have been completed, indicating a lapse in the facility's assessment and documentation processes.
Failure to Complete PASARR I Screening Prior to Admission
Penalty
Summary
The facility failed to complete a PASARR I (Pre-Admission Screening/Resident Review) screening prior to the admission of a resident diagnosed with multiple sclerosis and major depressive disorder. This resident, who was cognitively intact and required substantial assistance with activities of daily living, was admitted in July 2024. Upon review, no evidence was found in the resident's health record to indicate that the PASARR I was completed before admission. The Social Services Director confirmed that the PASARR I was not added to the resident's electronic health record, despite the resident being in the facility for over a month. This oversight placed the resident at risk for inappropriate placement and lack of needed services.
Failure to Follow Professional Standards in Medication Management
Penalty
Summary
Facility staff failed to adhere to professional standards of practice regarding the diagnosis and treatment of a resident's condition. The resident, admitted with diagnoses including stroke and depression, did not have a documented history of seizure disorder or epilepsy. Despite this, the resident was prescribed topiramate, an anticonvulsant, following a seizure episode after starting olanzapine, an antipsychotic medication. The resident experienced multiple seizures and was later hospitalized for sepsis due to a UTI. The facility's records, including the comprehensive care plan and MDS assessments, did not reflect a diagnosis of seizure disorder or epilepsy, raising concerns about the appropriateness of the anticonvulsant prescription. Interviews with facility staff revealed uncertainty about the cause of the seizures, with a pharmacist consultant suggesting that the seizures could have been related to the resident's recent COVID-19 infection or sepsis. The resident reported experiencing muscle cramps that appeared as convulsions when not administered gabapentin timely. The facility's administrator and interim DNS acknowledged that the nurse practitioner should have consulted with the physician regarding the epilepsy diagnosis, indicating a lapse in communication and coordination of care for the resident.
Failure to Assist Resident with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident who was dependent on staff for personal care. Resident 13, admitted in November 2023 with a history of stroke and chronic pain, had a care plan indicating a self-care deficit requiring substantial assistance with ADLs, including grooming. However, a review of the Documentation Survey Report on August 26, 2024, showed no records of personal hygiene care being provided to the resident during the day or evening shifts. Observations on multiple occasions revealed a brown stain on the resident's face, which was confirmed by staff. The facility's administrator and interim director of nursing services acknowledged that staff were expected to clean the resident's face, indicating a lapse in meeting the resident's care needs.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement care plan interventions for a resident at risk for falls, leading to a deficiency. The resident, admitted in May 2019, had a history of a fall and was diagnosed with a fracture of the left lower leg, dementia, and high blood pressure. The resident's care plan, updated in March 2024, identified the risk for falls and included an intervention to place a fall mat at the side of the bed, revised in April 2024. However, observations in August 2024 revealed that the fall mat was not placed at the bedside as required by the care plan. Staff members, including CNAs and an RNCM, were unaware of the requirement for a fall mat, despite it being documented in the care plan. The RNCM confirmed the absence of the fall mat, acknowledging the oversight in implementing the care plan intervention, which placed the resident at risk for injury.
Failure to Provide Timely PICC Dressing Care
Penalty
Summary
The facility failed to obtain a physician order and provide appropriate PICC dressing care for a resident, identified as Resident 146, who was admitted with a lung abscess and pneumonia. The resident's admission orders included central venous access care per facility protocol, but there was no physician order or resident-specific protocol documented for PICC dressing care. During the period from admission to 12 days later, there was no documentation indicating that the PICC dressing care was provided. On observation, the resident's PICC dressing was found to have been changed on the 12th day after admission, with the resident confirming that it had not been changed since admission. A registered nurse (RN) acknowledged changing the dressing on that day after noticing it had not been changed since admission and confirmed the lack of documentation and physician order. Another RN confirmed that the facility protocol required PICC dressings to be changed every seven days, which was not adhered to in this case.
Failure to Ensure Physician Visits for Resident
Penalty
Summary
The facility failed to ensure that a resident was seen by a physician, which was identified during a survey. The deficiency involved a resident who was admitted to the facility with diagnoses including a stroke and chronic pain. A review of the resident's clinical record revealed that there were no documented physician visits since the resident's admission. This was confirmed by the facility's Administrator and Social Services Supervisor during an interview.
Failure to Provide Prescribed Medications
Penalty
Summary
The facility failed to provide prescribed medications for one of the sampled residents, identified as Resident 147, who was admitted with a pelvis fracture. The physician's orders dated 8/22/24 included Preservision AREDs 2, psyllium oral capsules, and tolterodine tartrate, which were not available from 8/22/24 to 8/26/24. Staff 7, a CMA, confirmed that the medications were marked as unavailable on the MAR and admitted to not contacting the pharmacy or notifying the physician about the unavailability for five days. Staff 12, an RNCM, stated that medications should be available upon admission and that staff should check the cubex or contact the pharmacy if medications are unavailable. However, Staff 12 was unaware of the issue and expected staff to notify the pharmacy and physician within one day of recognizing the unavailability.
Failure to Implement Pharmacy Recommendations for Medication Order
Penalty
Summary
The facility failed to follow up on pharmacy recommendations for a resident admitted with insomnia. The resident was prescribed trazodone at bedtime for insomnia, with an additional tablet if not asleep within an hour. The pharmacist recommended discontinuing the current trazodone order and re-entering it with scheduled and PRN portions separated for proper administration charting. However, the June 2024 Medication Administration Record (MAR) showed that the trazodone order continued as previously prescribed, and the pharmacist's recommendations were not implemented. In July 2024, the pharmacist reiterated the same recommendation, and a handwritten note indicated it was done on July 15, 2024. Despite this, the July 2024 MAR revealed that the trazodone order remained unchanged until July 16, 2024, when it was added to the PRN section, indicating that the pharmacist's recommendations were not fully implemented.
Failure to Monitor Psychotropic Medications
Penalty
Summary
The facility failed to adequately monitor psychotropic medications for a resident, which placed them at risk for ineffective medication management. The resident was admitted with diagnoses including insomnia, depression, and pain, and was prescribed fluoxetine, trazodone, and olanzapine. The care plan required monitoring and documenting the side effects and effectiveness of these medications every shift. However, there was no documentation in the resident's clinical record to indicate that this monitoring occurred. Staff reported that when the facility switched systems for tracking clinical records, the monitoring of side effects was not included, and despite notifying management, it was not added. This lack of monitoring was confirmed by the facility's administrator and social services supervisor.
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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