Corvallis Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Corvallis, Oregon.
- Location
- 160 Ne Conifer Blvd, Corvallis, Oregon 97330
- CMS Provider Number
- 385072
- Inspections on file
- 33
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Corvallis Manor during CMS and state inspections, most recent first.
Surveyors found that the facility did not properly investigate two separate incidents involving two residents. In one case, a resident with muscle weakness and unsteadiness was found on the floor near an electric wheelchair after an unwitnessed fall, but the facility’s investigation lacked witness statements, a root cause analysis, and documentation ruling out abuse or neglect. In the other case, a resident with muscle weakness and diabetes reported a missing phone through a grievance and to the police, yet there was no documented investigation into how the phone went missing, and staff later acknowledged that such an investigation should have occurred.
A resident with a history of hip pain and a fractured thigh bone did not receive prescribed narcotic pain medication on multiple occasions due to medication unavailability and communication breakdowns between staff, providers, and the pharmacy. Documentation showed the resident experienced severe pain while awaiting the medication, and staff acknowledged delays in reordering and escalating the issue.
Two residents experienced significant delays in receiving care due to insufficient nursing staff and poor communication. One resident waited over 50 minutes for medication for constipation, while another, who was bedridden, waited 45 minutes for incontinence care and was told to wait until after meals. Staff confirmed these delays and the administrator acknowledged the expectation for call lights to be answered within 15 minutes.
A resident dependent on staff for toileting, with a history of stroke and language deficits, was left alone on the commode despite a care plan and posted instructions requiring staff presence. The assigned CNA was unaware of the updated care plan due to an unupdated Kardex, resulting in the resident experiencing distress and filing grievances regarding unmet needs and delayed assistance.
A resident with complex regional pain syndrome and anxiety did not receive prescribed eye drops due to unavailability, and a physician-approved substitution was delayed. Staff were aware of the medication shortage and the resident's repeated requests, but the new order was not implemented promptly, resulting in unmet care needs.
A resident with a history of stroke and language deficits, identified as a fall risk and dependent on staff for toileting, experienced a fall from the commode after the call light was not placed within reach as required by the care plan. Staff confirmed the call light was attached to the bed and not accessible, and the investigation into the incident was incomplete.
Two residents suffered significant injuries when staff failed to properly use a mechanical lift and did not follow care plan interventions. One resident fell headfirst from a Hoyer lift due to an unsecured sling strap, resulting in multiple brain and spinal injuries. Another resident, who required a two-person assist, was injured when a staff member provided care alone and failed to remove a broken call light clip, causing a skin tear and multiple bruises. Staff interviews and records confirmed that required safety checks and care plan protocols were not followed.
A resident with dementia and weakness was found with unexplained bruising, swelling, and pain in multiple areas. Staff assessed the injuries and notified supervisors, but did not complete a Facility Reported Incident (FRI) form or report the injuries as required. This failure to report and document the injuries of unknown origin resulted in a deficiency related to abuse and neglect reporting protocols.
The facility did not maintain proper food temperatures during meal service, resulting in cold and unpalatable meals for two residents, including one with cirrhosis and another with diabetes and malnutrition. Staff acknowledged equipment issues and residents reported dissatisfaction with food quality, including meals being served cold and not meeting dietary needs.
The facility failed to follow physician orders and implement care protocols for several residents, including missed administration of nutritional supplements and medications, lack of documentation for blood sugar checks, improper medication administration routes, delayed wound care due to unavailable supplies, and failure to monitor or address bowel and urinary issues. Staff interviews confirmed lapses in care, lack of timely physician notification, and unfamiliarity with required procedures.
A resident with cognitive impairment and mental health diagnoses was allowed to keep multiple medications in their room without proper assessment, monitoring, or documentation by staff. Staff did not consistently review administration instructions or track which medications the resident accessed or returned, resulting in unsecured medications and a lack of oversight.
A resident with cognitive capacity reported a missing cell phone to staff on multiple occasions, but no grievance was filed or assistance provided, despite staff awareness of the issue. Facility records confirmed no grievance was submitted, and staff interviews revealed a lack of knowledge about the grievance process and forms.
A resident with anxiety and PTSD was admitted and assessed through PASARR Level II, which recommended a recliner chair to address discomfort from prolonged wheelchair use. The recommendation was overlooked, and the resident did not receive the chair, with staff later acknowledging they were unaware of the PASARR guidance.
Two residents who required assistance with ADLs did not receive necessary personal hygiene care. One resident was repeatedly observed with long facial hair despite requesting its removal, and another resident with diabetes had long, dirty, and jagged fingernails, with required nail care not completed as scheduled. Staff interviews revealed confusion about responsibilities and a lack of direct assessment.
A resident with diabetes and vascular dementia developed redness and swelling of the left big toe, which was not properly monitored or evaluated as ordered. Documentation of physician orders and wound care was lacking, and the resident was discharged without the scheduled physician assessment. Upon admission to another facility, the resident was found to have an infected ingrown toenail with significant symptoms, confirming the lack of appropriate foot care and monitoring.
Water temperatures in both resident bathrooms and the therapy gym were found to be excessively high, with measurements reaching up to 141.6°F. Several residents with significant care needs, including those dependent on staff for toileting and mobility, were exposed to these unsafe conditions. Maintenance staff were unable to explain the discrepancy between boiler settings and actual water temperatures, and staff interviews confirmed that the issue had not been previously identified or addressed.
A resident with incomplete quadriplegia and a history of UTIs was allowed to self-catheterize without staff assessment or observation of their technique or hand hygiene. Staff set up supplies but did not verify if the resident performed the procedure in a clean manner, and there was no documentation of education or assessment related to infection prevention.
A resident with ESRD requiring hemodialysis did not have consistent completion of required Pre- and Post-Dialysis Assessment forms, with some forms missing vital information or left blank, and daily weights were not obtained or documented as ordered by the physician. Nursing staff and the DNS confirmed these lapses in communication and documentation between the facility and the dialysis provider.
A resident with dementia and a documented history of multiple forms of abuse was not provided trauma-informed care, as their care plan lacked interventions addressing trauma despite staff awareness of PTSD and behavioral concerns. The care plan focused only on cognitive impairment, and the resident's expressed interest in behavioral health support was not acted upon.
A resident on hospice care with cancer was provided with bilateral half bed rails without a documented assessment to determine safety risks or necessity. Staff interviews confirmed that required evaluations were not completed before the rails were applied, and maintenance and hospice staff were unaware of any assessment being conducted.
A resident with PTSD, agoraphobia, and bipolar disorder exhibited ongoing depressive symptoms, irritability, and refusal of care. Despite a physician's recommendation for a geriatric psychiatric referral, no mental health evaluation was documented or provided. Staff interviews confirmed the resident's continued isolation and refusal of care, and facility leadership acknowledged the lack of behavioral health services.
Three residents did not receive proper medication management, including a delayed dose reduction for a mood stabilizer, continued administration of a discontinued pain medication, and administration of an anti-hypertensive despite low blood pressure readings. Staff were unaware of or did not follow standing orders, and medication changes were not implemented as ordered.
A resident with kidney failure was evaluated for a suspected UTI, but the final urine culture results were not communicated to the physician for six days. During this time, the resident was not started on antibiotics and was not monitored for complications. Staff interviews confirmed the delay and acknowledged that timely follow-up was expected.
A resident admitted with a stroke diagnosis had blood samples collected and sent for thyroid hormone testing as ordered by a prescriber. The results of these tests were not found in the clinical record, and a consultant pharmacist noted the absence. An LPN unit manager confirmed the samples were sent but could not explain why the results were missing or why follow-up did not occur.
Two residents with special dietary needs did not receive requested or ordered menu items, including pizza and oatmeal, due to staff inaction and lack of process training. One resident's pizza request was not fulfilled after preparation, and another resident did not receive oatmeal listed on their breakfast ticket. Facility leadership confirmed that residents should receive the food items listed on their tickets.
A resident with incomplete quadriplegia and a history of UTIs continued to receive daily prophylactic trimethoprim even after a urine culture showed resistance to this antibiotic. The resident was also treated with amoxicillin for the acute infection, but the original antibiotic was not discontinued, and no provider documentation justified its continued use. Staff interviews confirmed the lack of appropriate antibiotic stewardship in this case.
Two residents experienced deficiencies in their living environment, including a fan with dusty blades and unresolved maintenance issues such as a non-functioning phone and room light. Staff reported delays in completing work orders, and one resident's family had to use 911 dispatch to contact them due to the broken phone. An LPN also had to use a cell phone light to provide wound care because the room light was out.
A resident with a Stage 3 pressure ulcer did not receive prescribed wound care and wound vac changes as ordered, due to staff not performing the treatment over a weekend. Staff initially cited a lack of supplies, but the unit manager confirmed the necessary materials were available. The missed treatment was not documented, and the physician was not notified.
A resident admitted with diabetes and a surgical site infection did not receive prescribed mealtime insulin upon arrival due to delays in pharmacy order processing and delivery. Nursing staff and the pharmacist confirmed that the medication request was submitted after the immediate delivery deadline, resulting in the resident's insulin being administered several hours late.
The facility did not consistently implement infection control precautions for three residents, including inconsistent use of gowns during catheter care, ongoing shortages of plastic bags, paper towels, and soap that impeded proper disposal of soiled linens and hand hygiene, and staff failing to use required PPE when entering a room of a resident on contact precautions. These actions and inactions were confirmed by staff, residents, and direct observation.
The facility failed to maintain the low temperature dish machine, risking foodborne illnesses. The dish machine's wash cycle temperatures were inadequate, leading to the use of paper products for meal service. Staff reported inconsistent water temperatures affecting both dishwashing and resident showers. Despite this, management instructed continued use of the dish machine, relying on chemical sanitizers. The issue was not addressed promptly, although a new hot water heater was ordered.
The facility failed to provide properly textured diets for two residents, one with Alzheimer's and another with a history of stroke. Both required pureed diets, but their meals contained improperly processed food, posing risks for aspiration. Staff acknowledged the inadequacy of the non-commercial food processor and the need for additional training.
The facility failed to provide sufficient nursing staff, resulting in delayed responses to resident call lights and unmet care needs. Observations and interviews revealed residents experiencing long wait times for assistance, with some waiting up to an hour. Resident Council Notes and witness statements confirmed ongoing staffing issues, particularly on weekends, affecting the timely provision of care.
Meals in the facility were not served at the proper temperatures, with eggs and milk failing to meet FDA guidelines. Residents and staff reported that meals were often late and cold, with one resident noting cold meals 75% of the time. A breakfast test tray confirmed the deficiency, with eggs at 91 degrees F and milk at 45 degrees F. Staff acknowledged the consistent issue of cold, unseasoned food served late.
The facility failed to maintain a safe and homelike environment in two resident rooms, where walls were in disrepair and baseboard coving was missing. This allowed outside air and cigarette smoke to enter the rooms, as confirmed by residents and staff. The issue was acknowledged by the facility's administrator and social service director, who noted that maintenance was aware and other rooms were similarly affected.
A resident with a left femur fracture was neglected in a facility, leading to a fall and subsequent hospital visit. The resident was found on the floor without footwear and with a soiled brief, having not been assisted with toileting for several hours. Staff interviews confirmed the resident's bed linens were soaked with urine and feces, and the resident had not received incontinence care all morning. The facility's investigation substantiated neglect of care.
The facility did not staff an RN for eight consecutive hours per day, seven days a week, for 22 out of 91 days reviewed. This deficiency was confirmed through interviews and record reviews, revealing specific days in January, February, and March 2024 without adequate RN coverage. The Administrator and DNS acknowledged the issue, which placed residents at risk for unmet assessment needs.
A resident with a history of adverse reactions to COVID-19 vaccines was administered a booster without consent or discussion of risks and benefits. The facility's administrator and DNS confirmed the oversight, which went against the resident's and family's wishes.
Failure to Investigate Unwitnessed Fall and Missing Personal Property
Penalty
Summary
The deficiency involves the facility’s failure to conduct a complete investigation of an unwitnessed fall for one resident. This resident was admitted with muscle weakness and unsteadiness on feet, and a public complaint alleged that the resident slept in a wheelchair and slipped out onto the floor. The facility’s unwitnessed fall investigation from that night documented that staff found the resident seated on the floor with the electric wheelchair positioned behind the resident at 12:20 AM, but the investigation lacked witness statements, a root cause analysis, and documentation confirming whether abuse or neglect had been ruled out. A registered nurse later stated she typically completed investigations for risk management but did not recall completing this unwitnessed fall investigation, and administration confirmed the investigation should have contained a root cause analysis, witness statements, and documentation excluding abuse or neglect. The deficiency also includes the facility’s failure to investigate a report of misappropriation of property for another resident. This resident, admitted with muscle weakness and diabetes, reported through a grievance that a phone that had been plugged in went missing around 1:00 AM, and a public complaint indicated the resident reported the missing phone to the police. Review of the clinical record showed no documentation of any investigation into the missing phone. The Social Services Director stated that an investigation should have been completed and noted the grievance focused on replacing the phone rather than determining how the phone went missing, and administration confirmed that an investigation into the missing phone should have been completed.
Failure to Provide Ordered Pain Medication Due to Communication and Refill Delays
Penalty
Summary
A resident admitted with right hip pain and a fractured thigh bone was prescribed hydrocodone-acetaminophen for pain management, to be administered every eight hours as needed for up to five days. Despite these orders, there were multiple documented instances where the resident did not receive the prescribed narcotic pain medication due to it being not available (NA) on the medication administration record (MAR). Specifically, doses were missed on several occasions, and staff notes indicated that the resident experienced severe pain during this period without access to the ordered medication. The deficiency was further compounded by communication issues between facility staff, the provider, and the pharmacy. Staff reported delays in reordering the medication and acknowledged that not all nurses had access to the provider communication system, making it the responsibility of Unit Managers to follow up on medication orders. The Director of Nursing confirmed that a refill for the narcotic medication was not sent to the pharmacy as required, and staff were expected to escalate such issues to management for resolution. These lapses resulted in the resident being without necessary pain medication for an extended period.
Delayed Response to Resident Needs Due to Insufficient Nursing Staff
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents in a timely manner, as evidenced by delays in responding to call lights and providing necessary care for two residents. One resident with a history of stroke and dementia was left waiting for assistance for over 50 minutes after requesting medication for constipation, despite a care plan directing staff to check on the resident frequently. The delay was attributed to poor communication between staff and low nurse staffing, with an agency CNA failing to promptly relay the medication request to the appropriate staff member. Another resident, who was bedridden and dependent on staff for all self-care, experienced a 45-minute wait for assistance with a brief change after activating the call light. The resident reported being told by staff to wait until after meals for incontinence care, which made the resident feel undignified. Staff confirmed the resident's dependence and preference for being changed before meals, and acknowledged the ongoing nature of the concern. The administrator stated that call lights were expected to be answered within 15 minutes and recognized the need for further investigation into the delays.
Failure to Provide Required ADL Assistance During Toileting
Penalty
Summary
A dependent resident with a history of stroke and language deficits, who was cognitively intact and required two staff for toileting assistance, did not receive the necessary assistance with activities of daily living (ADLs). The resident was admitted with a care plan indicating the need for staff to remain present while on the commode. Despite this, a grievance was filed after the resident was left on the commode for 30 minutes, and the resident specifically requested not to be left alone. The care plan was revised to reflect this preference, and signage was posted in the resident's room instructing staff not to leave the resident alone on the commode. However, staff interviews revealed that the CNA assigned to the resident was unaware of the updated care plan and the requirement to remain with the resident, as the Kardex had not been updated following a recent fall. During a time when the CNA was assisting another resident, other staff were instructed to assist, but the resident still experienced a delay in assistance and reported distress. The facility's investigation into the grievances did not identify the staff involved, and there was an expectation from leadership that the Kardex should have been updated and a thorough investigation conducted.
Failure to Provide Timely Eye Treatment per Physician Orders
Penalty
Summary
The facility failed to follow physician orders for eye treatments for one resident with complex regional pain syndrome and anxiety. Upon admission, the resident had a physician order for Optase (Glycerin) Comfort Dry Eye Solution to be applied twice daily. However, the medication was not available or on order from 7/2/25 through 7/10/25, and the resident did not receive the prescribed treatment during this period. Documentation shows that the resident repeatedly requested the eye drops, which increased their anxiety, and staff communicated with the pharmacy and the provider regarding the unavailability of the medication. On 7/7/25, a request was made to substitute the prescribed Optase with house stock Systane, and the physician approved this change. However, the new order for Systane was not implemented until 7/9/25, resulting in a delay in providing the necessary eye treatment. Staff interviews confirmed awareness of the medication shortage and the lack of a timely system to report or resolve missing medications. The delay in obtaining and administering the prescribed or substitute eye drops did not meet staff expectations and resulted in the resident's needs not being met as ordered.
Failure to Follow Fall Prevention Care Plan Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to follow a resident's care plan designed to prevent falls. The resident, who had a history of stroke and language deficits, was assessed as being at risk for falls and required the call light to be within reach at all times. Despite this, the resident experienced an unwitnessed fall from the commode, which was later attributed to the call light not being accessible. Staff interviews and documentation confirmed that the call light was attached to the resident's bed and not near the resident at the time of the incident. Further review revealed that the investigation into the fall was incomplete, lacking information about the cause or a conclusion. The resident reported being left on the commode for 30 minutes and specifically requested not to be left unattended. Multiple staff members, including an LPN and a CNA, acknowledged that the care plan was not followed, and facility leadership confirmed that the expected protocols were not adhered to in this case.
Failure to Prevent Accidents Due to Improper Use of Mechanical Lift and Non-Adherence to Care Plans
Penalty
Summary
The facility failed to ensure proper use of a mechanical lift (Hoyer) and adherence to care plan interventions, resulting in significant injuries to two residents. In one instance, a resident with Parkinson's disease and congestive heart failure, who was cognitively intact and required a two-person assist with a Hoyer lift, was being transferred from a raised bed to a shower chair. During the transfer, only three of the four sling straps were attached to the Hoyer, causing the resident to fall headfirst to the floor. The resident sustained a subarachnoid hemorrhage, intraparenchymal hemorrhage, scalp hematoma, and multiple compression fractures in the thoracic and lumbar spine. Staff interviews and observations confirmed that the sling was not properly secured, and the required safety checks were not performed prior to the transfer. In another case, a resident with dementia, weakness, and reduced mobility, who was severely cognitively impaired and required a two-person assist for turning and repositioning, suffered multiple injuries due to improper care. Staff failed to follow the care plan by attempting to provide care alone and not removing a broken, sharp call light clip from the resident's gown. This resulted in a skin tear on the resident's neck, bruising on the chest and right leg, and swelling and bruising on the left hand. Staff interviews revealed that the call light clip caused the skin tear when the blanket was pulled, and the resident was turned and dressed by a single staff member, contrary to the care plan. Both incidents were acknowledged by facility leadership, and documentation confirmed that the care plans and safety protocols were not followed, directly leading to the residents' injuries. The findings were based on observations, staff and resident interviews, and record reviews, which consistently indicated lapses in supervision and failure to prevent accident hazards as required.
Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report injuries of unknown origin for one resident who was admitted with dementia and weakness and required two-person assistance for turning and repositioning. On a specific date, staff observed the resident with bruising and discoloration on the right lower leg, swelling around the left hand, pain at the shoulder, and additional discoloration around the chest, none of which had been present the previous day. Staff members assessed the injuries and notified supervisory staff, but did not determine the cause of the bruising, and the resident was unable to describe how the injuries occurred. Despite the concerning findings, no Facility Reported Incident (FRI) form was completed for the resident. Staff involved acknowledged that an FRI form was not filled out, and one staff member stated she had never completed such a form before. The lack of timely reporting and documentation of the injuries of unknown origin constituted a failure to follow required abuse and neglect reporting protocols.
Failure to Maintain Safe and Appetizing Food Temperatures
Penalty
Summary
The facility failed to ensure that food temperatures were properly maintained during meal service, resulting in meals being served cold and unpalatable to residents. Observations during a lunch meal service revealed that the oven temperature was not maintained, causing delays in food preparation. Multiple undelivered lunch trays were stacked on top of an insulated cart due to insufficient space, and when a test tray was sampled, the food items were not warm and the pork was tough to cut. Staff acknowledged that the kitchen lacked sufficient and functioning equipment to keep food hot and of acceptable quality. Two residents were directly affected by these deficiencies. One resident, with a history of cirrhosis of the liver and high blood pressure, reported that mashed potatoes were soupy, broth was overly salty, and meals intended to be hot were served cold. This resident expressed dissatisfaction with the meals and reported going to bed hungry due to poor food quality. Another resident, diagnosed with diabetes and protein-calorie malnutrition, also reported that hot food was sometimes served cold. Staff confirmed these concerns and verified that residents should receive hot food at appropriate temperatures.
Failure to Follow Physician Orders and Implement Care Protocols
Penalty
Summary
The facility failed to follow physician orders, implement bowel care, and properly treat and monitor skin conditions for multiple residents, resulting in unmet needs. For one resident with a PEG tube and NPO status, staff did not consistently administer a physician-ordered nutritional supplement (Juven) as documented in the MAR, with several missed doses and no explanation provided in the clinical record. Additionally, blood sugar checks were not consistently documented, and there was a failure to clarify conflicting orders regarding the administration route for loperamide, with staff administering the medication through the G-tube despite the order specifying oral administration. Another resident with diabetes received fast-acting insulin significantly before a meal was provided, contrary to best practice and the medication's instructions, and was not given a snack to mitigate the risk of hypoglycemia. Staff acknowledged the delay in meal service and the lack of a snack, and the resident reported eating over an hour after insulin administration. For a resident with kidney failure, staff did not monitor for signs and symptoms of a UTI as ordered after the resident declined antibiotics, and there was no documentation of monitoring for complications, with staff confirming the lack of follow-up and unclear processes for physician notification. A resident with heart failure and end-stage kidney disease experienced an absence of bowel movements for eight days without evidence of monitoring, assessment, or implementation of bowel care protocols, and staff delayed notifying the physician and failed to ensure bowel care orders were in place upon admission. Another resident with diabetes and a surgical site infection did not receive timely wound vac treatment due to unavailable supplies and staff unfamiliarity with the wound vac process, resulting in missed and delayed wound care as documented in the treatment administration record and staff interviews.
Failure to Assess and Monitor Safe Self-Administration of Medications
Penalty
Summary
The facility failed to properly assess and monitor a resident for safe self-administration of medication. The resident, who had diagnoses including somatization disorder and PTSD, was determined by staff to have cognitive impairment and was not considered a candidate for unsupervised self-administration of medications. Despite this, the care plan allowed the resident to check out one medication per day to keep in their room, with staff expected to review administration instructions and document the resident's acknowledgment. However, there was no documentation in the clinical record indicating that staff reviewed instructions or that the resident checked out medications as required. Observations revealed that the resident had multiple nasal sprays and supplements in their room, both on the bedside table and in a large plastic tote. The resident stated they were allowed to keep medications in their room if kept organized. Staff interviews confirmed that the resident was permitted to keep certain medications at the bedside during the day but that staff did not monitor which medications were taken or returned, nor did they ensure medications were properly secured. The DNS acknowledged that the resident was not capable of safe self-administration and that staff were expected to follow the care plan, but these procedures were not followed.
Failure to Act on Resident Grievance for Missing Property
Penalty
Summary
The facility failed to ensure that a resident's grievance regarding missing property was acted upon in a timely manner. A resident admitted with fractures of the spine and pelvis, and documented as cognitively intact, reported her/his red cell phone missing on two occasions. Although the resident stated that staff were aware of the missing phone, no staff offered assistance to file a grievance, and the resident ultimately purchased a replacement phone. Review of facility grievance records showed no grievance form was submitted for the missing phone. Staff interviews confirmed awareness of the missing phone but revealed that no grievance was filed, and at least one staff member did not know where to locate a paper grievance form to assist the resident.
Failure to Implement PASARR Level II Recommendations for Resident with Mental Health Needs
Penalty
Summary
The facility failed to incorporate the PASARR Level II recommendations for a resident admitted with anxiety and post-traumatic stress disorder (PTSD). The PASARR Level II Mental Health Evaluation recommended providing a recliner-style chair for the resident, who reported discomfort from spending most of the day and night in a wheelchair and expressed a preference for sleeping in a recliner, as was their practice prior to admission. Despite this documented recommendation, the resident did not receive a recliner chair and had not received any updates regarding the request. Staff responsible for reviewing PASARR Level II results were unaware of the recommendations, and upon review, acknowledged that the recommendation had been overlooked.
Failure to Provide Required ADL Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents who required support. One resident, admitted with a history of stroke and muscle weakness and assessed as cognitively intact, required substantial to maximal assistance with personal hygiene. Despite care plans indicating the need for extensive support, this resident was repeatedly observed with significant facial hair and expressed a desire for its removal, stating that requests to staff had not resulted in the care being provided. Staff confirmed the presence of facial hair and acknowledged that it should have been addressed. Another resident, admitted with diabetes and also cognitively intact, required extensive assistance for bathing and hygiene, including diabetic nail care to be performed every two weeks. Observations revealed this resident had long, dirty, and jagged fingernails, and documentation showed that scheduled nail care was not completed as required. Staff interviews indicated confusion regarding responsibility for nail care, with CNAs and nurses each deferring to the other, and no direct assessment of the resident's nails was performed by the nurse responsible. The lack of proper nail care was confirmed by both observation and documentation.
Failure to Provide Appropriate Foot Care and Monitoring
Penalty
Summary
A resident with diabetes and vascular dementia was admitted to the facility and later developed redness and swelling of the left big toe, which was noted during an alert assessment. The area was cleansed, and the physician was notified, with instructions to monitor and provide supportive care. The resident was scheduled for a physician evaluation, but there was no documentation of monitoring or evaluation of the toe in the clinical record. Staff reported receiving a physician order for Epsom salt soaks, but no such order or wound evaluation was documented. The resident was subsequently discharged to another facility without evidence of the toe being evaluated by the physician as scheduled. Upon admission to the new facility, the resident was found to have an ingrown toenail with signs of infection, including increased drainage, pain, redness, inflammation, and eschar. The wound was measured and assessed as infected, and the physician at the new facility was notified. Interviews with staff and the physician confirmed that the toe was not evaluated as planned and that there was a lack of treatment and monitoring prior to discharge. Facility leadership acknowledged that the resident should have received treatment, monitoring, and physician observation of the wound before discharge.
Unsafe Water Temperatures in Resident and Therapy Areas
Penalty
Summary
The facility failed to ensure that water temperatures in resident areas and the therapy gym were maintained at safe levels, resulting in water temperatures that were significantly above recommended limits. Observations revealed that the water temperature in a shared resident bathroom reached 122 degrees Fahrenheit, despite the boiler being set at 114 degrees Fahrenheit. Maintenance staff were unable to explain the discrepancy between the boiler setting and the actual water temperature. Additionally, documentation showed that the water temperature in the physical therapy gym was recorded at 141.6 degrees Fahrenheit. Staff interviews confirmed that water temperatures were checked weekly, but there was no indication that the excessively high temperatures had been identified or addressed prior to the survey. Three residents with significant care needs, including those with heart disease, diabetes, and cancer, were identified as being at risk due to their dependence on staff for toileting and mobility. Staff interviews indicated that residents had not reported concerns about hot water, and in one case, it was noted that a resident did not use the affected bathroom. However, the presence of excessively hot water in both resident and therapy areas was confirmed through direct measurement and documentation, placing residents at risk for burns.
Failure to Assess and Monitor Resident's Self-Catheterization Practices
Penalty
Summary
The facility failed to assess a resident's ability to self-catheterize in a manner that would prevent urinary tract infections (UTIs). The resident, who had incomplete quadriplegia and a history of multiple UTIs, was able to move their arms but lacked fine motor function. Staff routinely set up catheter supplies for the resident but did not observe or assess the resident's technique or ability to maintain proper hand hygiene during the self-catheterization process. The care plan did not include specific instructions for staff to ensure a clean environment or to verify that the resident performed hand hygiene prior to catheterization. Multiple staff members, including CNAs, RNs, and LPNs, confirmed that they had not observed the resident perform self-catheterization or hand hygiene, and no documentation or assessment was available to demonstrate that the resident was able to perform the procedure safely. The bedside table was observed to have catheter supplies and a urinal, but no hand sanitizer was present. Despite the resident's history of UTIs related to self-catheterization, there was no evidence of education or assessment regarding infection prevention provided to the resident.
Failure to Ensure Accurate Dialysis Communication and Daily Weight Monitoring
Penalty
Summary
The facility failed to ensure accurate communication and documentation between the facility and the dialysis provider for a resident with end stage renal disease (ESRD) who required hemodialysis. Physician orders required staff to complete and send Pre- and Post-Dialysis Assessment and Communication forms with the resident to dialysis on specified days. Review of these forms revealed that some were incomplete, missing vital information such as post-dialysis vitals, comments, and signatures, while others were left entirely blank. Interviews with nursing staff and the Director of Nursing Services confirmed that the forms were not consistently completed or followed up on as required. Additionally, the facility did not obtain and document daily weights for the resident as ordered by the physician. Several days were identified where no weights were recorded, and staff interviews revealed uncertainty about the frequency of weighing the resident and the process for communicating this information. The Director of Nursing Services acknowledged that the resident's weights were not obtained daily as ordered, confirming a failure to follow physician instructions for monitoring the resident's condition.
Failure to Provide Trauma-Informed Care for Resident with History of Abuse
Penalty
Summary
A resident with a history of trauma, including suspected financial, sexual, verbal, emotional, and physical abuse, was admitted with diagnoses of psychotic disturbance, mood disturbance, and vascular dementia. The resident's care plan, revised after admission, addressed cognitive impairment and communication strategies but did not include interventions specific to trauma-informed care. Despite documentation from social services and an external physician noting the resident's trauma history and interest in behavioral health support, there was no evidence that trauma-specific needs were assessed or addressed in the care plan. Staff interviews revealed awareness of the resident's PTSD and behavioral responses, such as being jumpy and expressing fear during care activities. However, the Director of Social Services indicated no updates were received regarding the abuse investigation and did not consider the resident appropriate for counseling. Facility leadership confirmed that the care plan should have been individualized to address the resident's trauma history, but this was not done, resulting in a failure to provide trauma-informed care.
Failure to Assess Bed Rail Use Prior to Implementation
Penalty
Summary
A resident admitted with a diagnosis of cancer and on hospice services was observed to have bilateral half bed rails in place. The resident was cognitively intact and required extensive assistance for bed mobility, but stated that the rails were not used to turn. Review of the clinical record revealed there was no assessment conducted regarding the use of bed rails to determine if they posed a risk for entrapment or if they were necessary for the resident’s care. Interviews with staff confirmed that facility policy required an evaluation prior to implementing bed rails, including assessment of whether the rails functioned as a restraint, restricted movement, or posed an entrapment risk. Despite this, staff acknowledged that no such assessment was completed for this resident, even though there were orders for the rails. Maintenance staff were unaware of the rails being in place, and hospice staff confirmed that an assessment was not requested until after the rails had already been applied.
Failure to Provide Recommended Mental Health Services
Penalty
Summary
A resident with diagnoses of post-traumatic stress disorder, agoraphobia, and bipolar disorder was readmitted to the facility and exhibited ongoing depressive symptoms, irritability, and refusal of care, as documented in both the Minimum Data Set (MDS) assessment and physician progress notes. The physician recommended consideration of a referral for a geriatric psychiatric evaluation due to the resident's continued mental health symptoms. However, a review of the clinical record revealed that no referral for mental health evaluation was made, and there was no documentation of any behavioral health services being offered or provided to the resident. Staff interviews confirmed that the resident remained isolated in their room, often with the lights off, and frequently refused personal care. The Certified Nursing Assistant (CNA) described the resident as moody and irritable, with a pattern of refusing care. The Social Services Director was unaware of the physician's recommendation for behavioral health services and acknowledged that no referral had been documented or made. Facility leadership also confirmed that the resident did not receive a behavioral health evaluation, resulting in a failure to provide appropriate mental health services as recommended.
Failure to Appropriately Monitor and Administer Medications
Penalty
Summary
The facility failed to ensure appropriate monitoring and administration of medications for three residents. For one resident with a mental health disorder, a physician's order to decrease the dose of divalproex was not implemented for approximately a month, despite the order being documented in the medical record. This delay was confirmed by both the attending physician and the Director of Nursing Services (DNS). Another resident with Type II diabetes mellitus and neuropathy continued to receive tramadol for pain after a physician's order to discontinue the medication had been issued. Medication administration records showed multiple doses were given after the stop order, which was acknowledged by the DNS. A third resident with heart disease and chronic pain received metoprolol, an anti-hypertensive medication, even when their diastolic blood pressure was below the facility's standing order parameters. The standing orders required staff to hold anti-hypertensive medications if the diastolic blood pressure was below 60, but this was not followed. A certified medication aide (CMA) stated she was unaware of the standing orders and believed medications should only be held if specified on the medication administration record. The DNS confirmed that the medication should not have been administered under these circumstances.
Delayed Physician Notification of Lab Results for UTI
Penalty
Summary
The facility failed to promptly notify the ordering physician of laboratory results for a resident who was admitted with kidney failure and was being evaluated for a suspected urinary tract infection (UTI). Laboratory samples were collected, and while the initial urinalysis results were communicated to the physician, the final culture results were not reported until six days later. During this period, the resident was not started on antibiotic therapy, and staff did not monitor for complications. Interviews with staff confirmed that there was an expectation to follow up with physicians in a timely manner regarding lab results, and acknowledged that the delay in notification was not appropriate.
Missing Laboratory Results in Resident Record
Penalty
Summary
The facility failed to ensure that laboratory results were included in the clinical record for one resident who was admitted with a diagnosis of stroke. A prescriber ordered blood tests, including thyroid hormone levels, and staff collected and sent the blood samples to the lab. However, the results of the thyroid hormone test were not present in the resident's clinical record. A consultant pharmacist's review noted that the labs had been sent but the results were missing from the record, and staff were unable to provide a reason for the absence of the results or explain why there was no follow-up to ensure the results were obtained and filed.
Failure to Provide Requested and Ordered Menu Items to Residents
Penalty
Summary
The facility failed to ensure that residents' food preferences and menu selections were honored, resulting in two residents not receiving requested or ordered food items. One resident, admitted with anxiety and protein-calorie malnutrition, requested pizza, which was prepared and announced over the intercom, but the resident never received it. The agency CNA responsible was assisting another resident at the time and did not retrieve the pizza, and the dietary manager acknowledged that agency staff may not have been trained on the process for food requests. The resident later stated it was too late to receive the pizza. Another resident, admitted with diabetes and protein-calorie malnutrition, did not receive oatmeal that was listed on their breakfast food ticket. The resident confirmed the omission, and a staff member verified that oatmeal was not present on the tray. The dietary manager explained that oatmeal bowls are placed on food carts, and if they run out, staff are expected to obtain more from the kitchen. The resident stated it was too late to get the oatmeal after finishing breakfast. Facility leadership confirmed that residents should receive the items listed on their food tickets.
Failure to Discontinue Ineffective Prophylactic Antibiotic During UTI
Penalty
Summary
The facility failed to provide appropriate antibiotic stewardship for a resident with incomplete quadriplegia who had a history of urinary tract infections (UTIs) and was on daily prophylactic trimethoprim. Upon admission, the resident was self-catheterizing with staff assistance and continued on the prophylactic antibiotic. A urine culture later identified a UTI caused by an organism resistant to trimethoprim. Despite this, the resident continued to receive trimethoprim daily throughout the month, while also being prescribed a seven-day course of amoxicillin to treat the acute infection. Staff interviews confirmed that the prophylactic antibiotic was not discontinued after resistance was identified, and no documentation was provided to show that the resident's provider approved the continuation of trimethoprim. The Director of Nursing stated the antibiotic was continued to prevent other organisms, but the pharmacist indicated that the prophylactic antibiotic should have been held during the acute UTI unless a physician provided a specific rationale. This lack of action resulted in the continued use of an ineffective antibiotic without proper justification.
Failure to Maintain Cleanliness and Timely Repairs in Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and functional environment for two residents. One resident, admitted with heart disease, had a portable fan in their room with blades coated in a brown layer of dust. The Maintenance Director acknowledged the fan was dusty and was unsure who was responsible for cleaning the blades. The Housekeeping Manager stated that while the outside of fans were dusted daily, the blades were only cleaned when residents moved out of a room. Another resident, admitted with diabetes and a surgical site infection, experienced multiple issues with broken equipment in their room, including a non-functioning phone and room light. Work orders for these repairs were not completed in a timely manner, and staff were instructed to follow up on repair requests verbally. The resident's family was unable to reach them by phone and had to use 911 dispatch to make contact. An LPN reported needing to use a cell phone light to provide wound care due to the room light being out for three days. The facility administrator acknowledged that work orders were expected to be completed within 24 hours.
Failure to Provide Ordered Pressure Ulcer Treatment
Penalty
Summary
A resident with chronic pain and a Stage 3 pressure ulcer was admitted to the facility and had physician orders for wound care, including dressing changes and wound vac application three times per week. The care plan required staff to observe the wound dressing every shift and document wound observations during dressing changes. On a weekend, the resident did not receive the ordered wound treatment, and the wound vac was not changed as required. Staff interviews revealed that the wound treatment was missed due to an alleged lack of black foam needed for the wound vac, although the unit manager later confirmed that the black foam was in stock. There was no documentation or progress note related to the wound care for the missed treatment, and the physician was not informed about the missed wound care. This failure to follow physician orders placed the resident at risk for worsening of the pressure ulcer.
Failure to Provide Timely Insulin Administration Due to Delayed Pharmaceutical Services
Penalty
Summary
The facility failed to provide timely pharmaceutical services for a resident who was admitted with diagnoses including diabetes and a surgical site infection. Upon admission, the resident had hospital discharge orders for insulin to be administered three times daily with meals. However, documentation showed that the resident did not receive the prescribed lunchtime insulin dose on the day of admission, with the first insulin administration occurring later in the evening. Nursing notes indicated that the pharmacy received the prescription request after noon, and staff interviews confirmed that the resident's medications, including insulin, were not available upon arrival due to issues with the admission process and pharmacy delivery schedules. Further interviews with staff and the facility's pharmacist revealed that the pharmacy received the general medication order request after the deadline for immediate delivery, and an urgent request for insulin was not made until mid-afternoon, resulting in delivery several hours later. The Director of Nursing Services acknowledged that medications should be in place before a resident's arrival. This sequence of events led to a delay in the administration of essential insulin therapy as ordered for the resident.
Failure to Follow Infection Control Standards and Maintain Adequate Supplies
Penalty
Summary
The facility failed to adhere to infection control standards for contact and Enhanced Barrier Precautions for three residents. One resident with sepsis and a Foley catheter was placed on enhanced barrier precautions per physician order and care plan, but staff and family reported inconsistent use of gowns during catheter care. Staff confirmed that gowns were not consistently worn in precaution rooms prior to a certain date, despite expectations for immediate implementation of precautions. Another resident with diarrhea and a UTI was care planned for hand hygiene education and was on antibiotic prophylaxis. Multiple staff and the resident reported ongoing shortages of plastic bags, paper towels, and soap, which hindered the proper removal of soiled linens and appropriate hand hygiene. Staff described having to carry soiled items through hallways or dispose of them in unlined garbage cans, and confirmed that supply shortages were a recurring issue, sometimes related to housekeeping budget constraints and supply management practices. A third resident with a Stage 3 pressure ulcer and a positive wound culture was placed on contact precautions, with signage indicating the need for gowns and gloves. However, staff were observed entering the resident's room and handling personal items without donning the required personal protective equipment (PPE). Some staff stated they believed PPE was only necessary for direct contact, despite the posted precautions and infection preventionist's confirmation that PPE was required when within three feet of the resident or touching personal belongings.
Failure to Maintain Essential Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment, specifically the low temperature dish machine, which placed residents at risk for foodborne illnesses. The dish machine's wash cycle temperatures were required to remain between 120 to 140 degrees Fahrenheit, but logs indicated that the temperatures only reached 120 degrees on specific dates. A work order was submitted by the Dietary Manager due to insufficient hot water, marked as high priority, but was not addressed in a timely manner. The Regional Director of Maintenance marked the issue as completed, but the problem persisted, leading to the use of paper products for meal service when water temperatures were inadequate. Staff interviews revealed that the dish machine's water temperatures were inconsistent, with reports of cold water affecting both dishwashing and resident showers. Despite the inadequate temperatures, management instructed staff to continue using the dish machine, relying on chemical sanitizers. The Regional Dietary Manager acknowledged that the dish machine did not meet the expected wash cycle temperatures, and the Regional Director of Maintenance admitted that the priority work order was not processed promptly, although a new hot water heater was ordered.
Failure to Provide Properly Textured Diets
Penalty
Summary
The facility failed to provide modified textured diets as ordered for two residents, leading to potential risks for medical complications and aspiration. Resident 1, diagnosed with Alzheimer's disease and mood disturbance, required a pureed diet due to swallowing issues. However, on one occasion, a chunk of meat was found in the resident's pureed food, which was not completely processed. Staff 12, the cook, acknowledged the issue, and Staff 10, a CMA, reported the concern to the Dietary Manager. The Dietary Manager, Staff 4, was aware that the non-commercial food processor purchased was inadequate for ensuring a smooth consistency for pureed diets. Resident 2, with a history of stroke and heart disease, also required a pureed diet. The resident was observed with a plate of pureed food that contained small pieces of food, indicating it was not smooth in texture. Staff 4 admitted to not receiving official training related to diet textures, and Staff 9, an SLP, confirmed the food texture did not meet expectations. Staff 12 expressed concerns about the safety of the pureed food texture, and the Regional Dietary Manager, Staff 8, acknowledged the need for additional staff training.
Staffing Deficiency Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff to maintain the highest practicable physical and psychosocial well-being for residents, as evidenced by multiple observations and interviews. On one occasion, a resident was found with a soiled brief and expressed distress due to a lack of staff response to their call light. The staff member nearby was unable to assist immediately due to being behind schedule. Additionally, several other call lights were observed to be activated, indicating a delay in response to resident needs. Resident Council Notes from August to October 2024 highlighted ongoing concerns about long wait times for call lights, particularly on weekends, and staff expressing frustration about short staffing. Multiple residents and witnesses reported similar issues, with some residents experiencing delays of up to an hour for assistance. A family member also noted the difficulty in finding enough staff to assist with two-person tasks. The Director of Nursing Services acknowledged the staffing concerns, confirming the deficiency in meeting resident needs promptly.
Meals Served at Improper Temperatures
Penalty
Summary
Meals were not served at the proper temperature in the facility's kitchen, as observed during a survey. The Food and Drug Administration guidelines require eggs to be served at 135 degrees F or above and milk at 40 degrees F or below. However, during a breakfast test tray conducted with the Administrator and Dietary Manager, the eggs were found to be at 91 degrees F and the milk at 45 degrees F, both below the required temperatures. Residents expressed concerns about late meal service and cold food in the August and September 2024 Resident Council Notes. Multiple residents and a complainant reported that meals were often served late and cold, with one resident stating that meals were cold 75% of the time. Staff members, including dietary aides and a CNA, confirmed that food was consistently cold, lacked seasonings, and was often served late. The Dietary Manager verified that there was a delay between the meal cart being ready and the last resident tray being served.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, comfortable, and homelike environment for residents in two of the three rooms reviewed, specifically Rooms 117 and 118. Observations revealed that the walls underneath the windows in these rooms were in disrepair, and the baseboard coving was missing. This condition allowed outside air and odors, including cigarette smoke from a nearby outdoor smoking area, to enter the rooms. Witnesses, including a complainant and a resident, confirmed the presence of drafts and smoke odors, with staff resorting to placing towels around the affected areas to mitigate the issue. The facility's administrator and social service director acknowledged the problem, noting that maintenance was aware and that other rooms were similarly affected due to heater replacements.
Neglect of Resident Care Leading to Fall and Hospitalization
Penalty
Summary
The facility failed to ensure a resident's right to be free from neglect, which placed the resident at risk for unmet care needs. The resident, admitted with a left femur fracture, was to be assisted with toileting every two hours and required appropriate footwear for ambulation or transfers. On the day of the incident, the resident was found on the floor without socks or shoes and with a soiled brief, indicating neglect of care. The resident had not been assisted with toileting for several hours, and the call light was not on. Staff interviews revealed that the resident's bed linens were soaked with urine and feces, and the resident had not received incontinence care all morning. The facility's investigation confirmed neglect of care, as the resident had not been checked on as required. Staff members acknowledged the neglect, noting that the resident's condition was unusual and that the resident typically communicated the need for assistance. The investigation concluded that the resident may have attempted to use the bathroom independently, leading to the fall. The resident was later diagnosed with a urinary tract infection at the hospital, although no injuries from the fall were reported.
Failure to Provide RN Coverage for Required Hours
Penalty
Summary
The facility failed to staff a registered nurse (RN) for eight consecutive hours per day, seven days a week, for 22 out of 91 days reviewed. This deficiency was identified through interviews and record reviews, including the facility's Direct Care Staff Daily Reports and payroll documents. The specific days without adequate RN coverage were noted in January, February, and March 2024. On June 17, 2024, during an interview, the Administrator and the Director of Nursing Services (DNS) acknowledged the lack of RN coverage on the specified days. The Administrator stated that she expected RN coverage for eight hours each day, but this expectation was not met, placing residents at risk for unmet assessment needs.
Failure to Obtain Consent for COVID-19 Vaccination
Penalty
Summary
The facility failed to obtain consent and discuss the risks and benefits of the COVID-19 vaccination with a resident or their representatives before administration. This deficiency involved a resident who was admitted with diagnoses including COVID-19 and heart failure. The resident's immunization record indicated that a COVID-19 booster was administered, but there was no documentation in the medical record showing that the risks and benefits were discussed with the resident or their representatives. A complainant stated that the vaccine was given against the wishes of the resident and their family, who had previously informed the facility of the resident's adverse reactions to past COVID-19 vaccinations. The facility's administrator and DNS confirmed that the vaccine was administered without the necessary education and consent.
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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