Cottage Grove Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Cottage Grove, Oregon.
- Location
- 515 Grant Street, Cottage Grove, Oregon 97424
- CMS Provider Number
- 385152
- Inspections on file
- 19
- Latest survey
- June 27, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Cottage Grove Post Acute during CMS and state inspections, most recent first.
Two residents did not receive their prescribed pain medications due to the facility running out of stock and failing to reorder in a timely manner. One resident, on hospice care and with a history of chronic pain, missed multiple doses of morphine, developed opioid withdrawal symptoms, and required hospitalization. Another resident with chronic joint pain missed several doses of Lyrica, resulting in severe pain that was not relieved by non-pharmacological interventions. Staff interviews confirmed ongoing issues with medication reordering and communication with providers.
Several residents, including those with reduced mobility, kidney disease, Multiple Sclerosis, and schizoaffective disorder, did not have their required MDS assessments completed on time. The LPN MDS Coordinator reported being behind due to workload, resulting in overdue Annual, Quarterly, and Discharge MDS assessments. Facility leadership confirmed that timely completion of MDS assessments is the expected standard.
Surveyors found that the facility did not consistently provide palatable or appetizing meals, as evidenced by overcooked pasta, bland vegetables, and flavorless bread and meatballs. Two residents reported dissatisfaction with the food, describing it as bland, sometimes cold, and unappealing. The Dietary Manager and Administrator confirmed the issues after sampling the meal.
Staff failed to prevent a resident from handling PPE supplies without sanitization, allowed soiled items to be placed near clean water and ice supplies, and did not implement enhanced barrier precautions or proper signage for a resident with open wounds. Multiple staff provided wound care without PPE, and staff were unaware of required precautions due to inconsistent care plan updates.
A resident with heart and kidney disease was transferred to the hospital for symptoms such as nausea, diarrhea, malaise, cold sweats, and dizziness, but the physician was not notified of the transfer. Review of records and staff interviews confirmed the lack of physician notification.
A resident with anxiety and reduced mobility reported missing six packs of cigarettes from a locked storage box at the nurses' station. Facility policy required smoking materials to be stored in these boxes, but it was found that the keys could open multiple boxes and the drawer was not consistently locked. Staff confirmed the security issues, and the facility lacked adequate tracking and safeguarding of residents' property, resulting in the loss.
A resident with heart and kidney disease was transferred to the hospital for symptoms such as nausea, diarrhea, malaise, cold sweats, and dizziness, but the facility did not provide the receiving provider with the responsible practitioner's contact information, advance directive details, or medication information prior to transfer. The DNS could not produce documentation confirming this information was communicated.
A resident with heart and kidney disease was discharged from hospice, but staff did not complete the required Significant Change MDS assessment within the mandated timeframe. The LPN/MDS Coordinator did not discuss the change with the resident or perform the assessment, and the DNS confirmed the oversight.
A resident admitted with multiple sclerosis and a Stage 3 pressure ulcer did not have a baseline care plan addressing wound care needs completed within 48 hours of admission. Staff confirmed that a care plan should have been initiated upon admission, but review of records and interviews revealed this was not done.
Two residents did not receive care as ordered by their physicians, including missed weight monitoring for a resident with heart failure and missed doses of Austedo for a resident with schizoaffective disorder due to medication unavailability. Documentation was inconsistent, and staff did not always notify the PCP promptly when issues arose.
A resident's pain medication was misappropriated due to a failure in following the facility's policy on handling controlled substances. An LPN received a package of narcotics but did not verify its contents and left it unattended. Another LPN later discovered the medication was missing, and the facility acknowledged the policy was not followed.
The facility failed to store narcotic pain medications safely, as required by policy, leading to the misappropriation of a medication card containing oxycodone tablets. Narcotic medications were left unattended and visible behind the nursing station, contrary to the policy of storing them in locked compartments. Staff interviews confirmed the lapse in procedure, and the incident was reported to law enforcement.
Failure to Provide Timely Pain Medication Results in Unmanaged Pain and Hospitalization
Penalty
Summary
The facility failed to provide appropriate pain management for two residents who required such services, resulting in significant lapses in care. One resident, who was cognitively intact and had a history of heart and kidney disease, was admitted to hospice and had physician orders for scheduled and PRN morphine for pain and shortness of breath. The facility ran out of the resident's prescribed morphine, and staff did not reorder the medication in a timely manner. As a result, the resident went several days without receiving the narcotic pain medication, experienced unmanaged pain, and developed symptoms consistent with opioid withdrawal, including nausea, vomiting, diarrhea, cold sweats, and elevated blood pressure. The resident was ultimately transferred to the hospital for evaluation and treatment. Documentation confirmed that seven doses of morphine were missed due to the medication being unavailable or not administered, and staff interviews revealed ongoing issues with medication reordering processes and communication with the on-call provider. Another resident with polyosteoarthritis had a physician order for Lyrica twice daily for pain management. The facility ran out of Lyrica, and the resident did not receive the medication for several doses over multiple days. During this period, the resident's pain levels fluctuated from 0/10 to 10/10, and non-pharmacological interventions were attempted but were not effective. Staff acknowledged that there was no designated person responsible for reordering medications, leading to frequent medication shortages, especially over weekends. The resident reported experiencing constant pain and stated that running out of pain medication was a recurring issue. In both cases, the facility's failure to maintain adequate medication supplies and ensure timely reordering directly resulted in residents experiencing unmanaged pain and, in one case, opioid withdrawal and hospitalization. Staff interviews and documentation confirmed that the medication management system was ineffective, with lapses in communication and follow-through on medication orders.
Failure to Complete Timely MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete Minimum Data Set (MDS) assessments in a timely manner for four out of eight sampled residents. For one resident with reduced mobility and muscle wasting, the Discharge Return Not Anticipated MDS assessment was overdue by nine days. The MDS Coordinator confirmed being behind on work due to a busy schedule, resulting in the late assessment. Another resident with kidney disease and heart failure had an Annual MDS assessment overdue by thirteen days, with the same explanation provided by the MDS Coordinator. Additionally, a resident with Multiple Sclerosis had a Quarterly MDS assessment completed three days late. Another resident with schizoaffective disorder had both an Annual MDS and a Quarterly MDS completed late, with the Annual MDS overdue by over two weeks and the Quarterly MDS overdue by several days. The MDS Coordinator acknowledged the delays in all cases, and facility leadership confirmed that the expectation was for MDS assessments to be completed on time.
Failure to Provide Palatable and Appetizing Food
Penalty
Summary
The facility failed to provide palatable, attractive, and appetizing food to residents, as evidenced by observations, interviews, and test tray sampling. During a lunch meal service, the spaghetti noodles were found to be mushy, soft, and overcooked, the herb green beans tasted metallic and bland, and the garlic bread stick was doughy with no garlic flavor. The meat sauce was described as flavorful, but the meatball lacked flavor. The Dietary Manager confirmed these findings after sampling the meal, noting the pasta was soft, the green beans lacked taste, and the bread stick may have softened while sitting in the steam table. The Administrator acknowledged that overcooked pasta should not be a regular occurrence and expected the menu items to have the appropriate flavors. Two residents expressed dissatisfaction with the food. One resident, with a diagnosis of quadriplegia, reported that the vegetables were overcooked and bland. Another resident, with a history of depression, stated the food was terrible, sometimes cold, and the meat was occasionally too tough. This resident also reported that the spaghetti and meatball served for lunch were bland and needed more seasoning. These findings were consistent with the test tray results and staff observations, indicating a failure to consistently provide palatable and appetizing meals as required.
Failure to Follow Infection Control Standards and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control standards in multiple instances. On one hall, a resident was observed handling various items in a PPE cart, including masks and a stethoscope, for several minutes without staff intervention or subsequent sanitization of the cart. Although a staff member was present during the incident, no immediate action was taken to prevent the resident from touching the items or to clean the cart afterward. Staff later acknowledged that this did not align with infection control protocols. Additionally, on the same hall, a water pitcher cart was found near a room under enhanced barrier precautions (EBP) with an uncovered ice scoop and a soiled cup placed next to clean items, such as gloves and straws. Staff admitted that it was difficult to prevent residents from placing dirty items on the cart and that the presence of soiled items was not in line with best practices. Furthermore, a resident with open wounds requiring daily and twice-daily wound care did not have appropriate EBP signage posted outside their room, and multiple staff members provided care without donning PPE. Staff involved were unaware of the need for precautions and confirmed that care plans and signage were not consistently updated.
Failure to Notify Physician of Resident Hospitalization
Penalty
Summary
The facility failed to notify a resident's physician when the resident was discharged to the hospital. The resident, who had a history of heart disease and kidney disease, was admitted to the facility in October 2024. On June 8, 2025, the resident was sent to the hospital due to symptoms including nausea, diarrhea, general malaise, cold sweats, and dizziness. A review of the clinical record showed no documentation that the physician was informed of the hospital transfer. Interviews with facility staff confirmed that the physician was not notified at the time of the resident's hospitalization.
Failure to Safeguard Resident Personal Property
Penalty
Summary
A resident with anxiety and reduced mobility, who was cognitively intact, reported the loss of six packs of cigarettes from a locked storage box at the nurses' station. Facility policy required residents to store smoking materials in these locked boxes, with residents keeping a key and staff assisting with access. However, it was observed that the keys distributed to residents could open multiple boxes, compromising the security of personal property. The resident expressed concerns about the effectiveness of the locks and declined to store cigarettes at the nurses' station due to this issue. Staff interviews and observations confirmed that the drawer containing the cigarette storage boxes was not consistently kept locked, and a master key capable of opening multiple boxes was accessible in the same drawer. The facility's process for tracking and safeguarding residents' smoking materials was insufficient, as evidenced by the missing cigarettes and the lack of evidence regarding their existence. These lapses in securing residents' property led to the deficiency cited in the report.
Failure to Communicate Required Information During Hospital Transfer
Penalty
Summary
The facility failed to ensure that appropriate information was communicated to the receiving health care institution or provider prior to the transfer of a resident to the hospital. Specifically, for a resident admitted with heart disease and kidney disease, there was no evidence in the clinical record that the facility provided the contact information of the practitioner responsible for the resident's care, advance directive information, or details regarding medications (including when last received) before the resident was sent to the hospital for symptoms including nausea, diarrhea, general malaise, cold sweats, and dizziness. During an interview, the Director of Nursing Services was unable to provide documentation confirming that this information was given to the hospital prior to the resident's transfer.
Failure to Complete Significant Change MDS Assessment After Hospice Discharge
Penalty
Summary
The facility failed to complete a Significant Change MDS assessment (SCSA) within the required 14 days after a significant change in condition for a resident who was discharged from hospice care. The resident, admitted with heart and kidney disease, was noted to be cognitively intact and on hospice as of the last quarterly MDS. Staff confirmed that the resident graduated from hospice, but the MDS Coordinator did not discuss this change with the resident or complete the required SCSA. The Director of Nursing also acknowledged that the SCSA was not completed following the resident's discharge from hospice.
Failure to Initiate Baseline Care Plan for Pressure Ulcer
Penalty
Summary
The facility failed to complete a baseline care plan within 48 hours of admission for a resident with a Stage 3 pressure ulcer. The resident, who was admitted with multiple sclerosis and a Stage 3 pressure ulcer, did not have a baseline care plan addressing wound care needs documented in the care plan review. Observations confirmed the presence of the pressure ulcer, and staff interviews acknowledged that a care plan focused on the wound should have been initiated upon admission but was not completed. Record review and staff statements confirmed the absence of a timely baseline care plan for the resident's pressure ulcer.
Failure to Follow Physician Orders and Ensure Medication Availability
Penalty
Summary
The facility failed to follow physician orders and ensure proper documentation for two residents with significant medical needs. One resident with hypertensive heart disease and heart failure had physician orders for regular weight monitoring, including daily and weekly weights, to support cardiac management. However, the resident's weight was only documented a fraction of the required times, with inconsistent use of codes such as 'NA' and 'code six' without clear definitions. Staff interviews confirmed that weights or refusals were not consistently documented as expected, and there was a lack of clarity regarding the documentation process. Another resident with schizoaffective disorder and drug-induced dyskinesia did not receive prescribed doses of Austedo on multiple occasions due to the medication being unavailable. Documentation showed that the pharmacy was contacted after several missed doses, and there were delays in notifying the primary care provider (PCP) about the missed medication. The resident reported feeling the effects of missing the medication, and staff acknowledged that medications should be ordered in advance to prevent running out, with prompt notification to the PCP when medications are unavailable.
Misappropriation of Resident's Pain Medication
Penalty
Summary
The facility failed to ensure the proper handling and documentation of controlled substances, leading to the misappropriation of a resident's pain medication. A resident, who was admitted with a leg fracture, was supposed to receive a card of oxycodone containing 14 tablets. The medication was delivered to the facility along with other narcotics, but it was not properly checked or secured. Staff 4, an LPN, received the package but did not verify its contents and left it unattended at the nursing station. Later, Staff 3, another LPN, discovered that the resident's medication was missing. Interviews revealed that Staff 4 did not maintain direct observation of the medication package from the time it arrived until it was discovered missing. Staff 3, who was on break when the medications were delivered, was not informed about the delivery and only noticed the package later. The facility's policy on ordering and receiving controlled medications was not followed, as acknowledged by Staff 1. The incident was reported to law enforcement, but the facility could not substantiate the misappropriation at the time of the investigation.
Improper Storage of Narcotic Medications
Penalty
Summary
The facility failed to store narcotic pain medications in a safe manner, which placed residents at risk for misappropriation of medications. The facility's Controlled Medication Storage policy required narcotic pain medication to be maintained in separately locked, permanently affixed compartments. However, on a specific date, narcotic medications were delivered to the facility and were not stored according to this policy. Instead, the medications were placed behind the nursing station, visible to anyone, and not under direct observation. This lapse in procedure led to the discovery that a medication card of 14 tablets of oxycodone for a resident was missing. Interviews with staff revealed that the narcotic medications were received by an LPN who did not check the contents of the package and left it unattended. Another LPN noticed the package sitting on a computer at the nurse's station after returning from a break. The facility acknowledged that the policy was not followed, leading to the improper storage of narcotic pain medications. The incident was reported, and law enforcement was notified, but the resident did not miss any doses of pain medication.
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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