Creswell Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Creswell, Oregon.
- Location
- 735 South 2nd Street, Creswell, Oregon 97426
- CMS Provider Number
- 385182
- Inspections on file
- 25
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 29
Citation history
Health deficiencies cited at Creswell Post Acute during CMS and state inspections, most recent first.
A resident with dementia and behavioral disturbance was found with a bruise to the left eye, and staff could not determine the cause of the injury. Although a CNA reported the bruise to an LPN, the incident was not reported to the State Survey Agency in a timely manner, resulting in non-compliance with reporting requirements.
A resident was discharged without a documented discharge plan, as required. Review of the clinical record showed the discharge plan was overdue, and neither the care plan nor care conference notes addressed the resident's discharge preferences. Staff interviews confirmed the discharge plan was not completed and revealed a lack of familiarity with the discharge planning procedure.
Two residents with complex medical needs, including a fractured femur, osteoarthritis, pressure ulcer, and chronic kidney disease, did not have their required MDS assessments completed on time. Staff confirmed that these assessments were overdue and acknowledged the delay.
A resident with dementia was involved in incidents of agitation and physical aggression, but the care plan was not updated in a timely manner to include interventions to prevent further occurrences. The care plan revision was delayed despite the identification of necessary interventions after the initial incident, as confirmed by the DON.
Two residents with chronic medical conditions and intact cognition experienced prolonged call light wait times of 40 and 47 minutes. Staff members reported being occupied with other duties or lacking communication devices, and the DON confirmed that these wait times were too long.
The facility failed to provide complete discharge summaries for three residents, omitting essential information from their most recent assessments. A resident with diabetes, another with heart failure, and a third with dementia had discharge summaries lacking details on functional abilities, urinary incontinence, psychosocial well-being, nutritional status, dental care, pressure ulcers, and pain. This was acknowledged by the DNS during an interview.
The facility failed to properly store and label medications and biologicals, as observed during audits of a treatment cart and a medication refrigerator. An open vial of Insulin Glargine was found to be over 28 days old, and an undated tuberculin vial and expired Spikevax vaccines were discovered. Staff confirmed these findings and acknowledged the need for proper labeling and disposal.
The facility failed to follow physician orders and provide timely care, resulting in deficiencies. A resident had bed rails removed without notification, another experienced delayed bowel care and inconsistent pain medication administration, and a resident consumed excess alcohol during an outing. Medication administration delays were common, with staff citing high acuity and workload as reasons. Residents expressed dissatisfaction with these delays.
A facility failed to obtain consent for an influenza vaccination for a cognitively intact resident with diabetes. The resident received the vaccine, but a review of their medical record showed no signed consent. The DNS confirmed the absence of consent, acknowledging it should have been obtained before vaccination.
The facility failed to notify emergency contacts and a physician in two cases. A resident hospitalized for abdominal issues had no emergency contacts informed, despite being cognitively intact. Another resident, post-spinal surgery, developed a lump on the back, but the physician was not notified, although the family was informed. Staff later acknowledged these communication lapses.
A resident, who was cognitively intact and had diabetes, reported that her/his cell phone was stolen, leading to a $300 replacement cost. Despite informing social services, no grievance form was completed. The staff acknowledged the need for a grievance form and investigation.
A facility failed to provide a bed hold policy to a resident during hospitalization, which is necessary to inform them of their rights to return. The resident, admitted in 2018 with delayed stomach and intestine emptying, was hospitalized multiple times without receiving the policy. Social Services staff stated that they provided the policy if present, but nursing staff were responsible after hours or on weekends. It was confirmed that the resident did not receive the policy during their hospitalizations.
A resident admitted with paralysis after spinal surgery did not have a baseline care plan that included necessary spinal precautions. The care plan was updated over a week later to include log-rolling and spinal precautions, but the resident reported staff did not follow these directions. Staff interviews revealed a lack of effective communication and documentation of the necessary precautions.
A resident with third-degree burns was discharged from an LTC facility without proper wound care training or home health support, leading to hospital readmission for infected wounds. The facility failed to ensure the resident or their roommate received necessary wound care instructions, resulting in a lack of adequate post-discharge care.
A resident with severe cognitive deficits did not receive necessary assistance with ADLs, including regular showers and nail care, as required. Observations showed the resident had dirty hair and fingernails, and documentation lacked evidence of refusal for missed bathing dates. Staff confirmed the resident should have received showers twice a week.
The facility failed to assist two residents in obtaining prescription glasses, risking impaired vision. One resident, admitted with bowel and stomach dysfunction, did not receive glasses despite a new prescription. Social Services staff were unaware of the prescription. Another resident with diabetes experienced a delay in receiving glasses after an ophthalmologist visit, with no staff follow-up recorded. Staff acknowledged the issue but had not completed the order through insurance.
A resident with a right finger contracture did not receive a necessary splint, despite assessments and referrals indicating its need. The care plan did not include the splint, and staff were unaware or had not seen the splint applied. This oversight was identified as a deficiency in the facility's care.
A facility failed to maintain a medication error rate below five percent, with two errors in 39 opportunities. A resident with chronic conditions did not receive Creon at the prescribed time, and staff failed to ensure mouth rinsing after Advair Diskus use, as per physician orders.
A resident admitted with diabetes, who was cognitively intact, signed an arbitration agreement but later did not recall doing so, citing heavy medication and lack of follow-up. The Social Service Director, responsible for explaining and managing arbitration agreements, confirmed that she did not follow up with residents after they signed, considering it a one-time task. This led to a deficiency in ensuring the resident's understanding of the agreement.
A resident with post-surgical paraplegia, who was cognitively intact, experienced a dignity-related deficiency when a CNA initially refused to change wet sheets, causing the resident frustration and fear. The CNA eventually changed the sheets after initially insisting they were not wet. The DNS confirmed that staff should honor such requests.
A resident's right to privacy was violated when a staff member at an LTC facility opened their mail without permission. The resident, who was cognitively intact and had diabetes, reported the incident, which involved a package containing supplements. Staff acknowledged the error, emphasizing that mail should be delivered unopened, and staff should only be present when residents open suspected medication packages.
A resident admitted with paralysis developed a pressure ulcer due to inconsistent implementation of a care plan aimed at preventing such injuries. Despite being at risk, the resident was not consistently turned every two hours, and education on positioning was not regularly provided. Staff acknowledged challenges in adhering to care standards, contributing to the development of a deep tissue injury.
A resident with moderate cognitive impairment and a history of alcohol use consumed more beer than the physician-ordered limit during an outing. Two staff members failed to supervise the resident adequately, allowing the resident to drink additional beers provided by a non-staff member. The resident returned to the facility with altered vital signs, and the staff did not report the excess alcohol consumption to the nurse.
Failure to Timely Report Injury of Unknown Source
Penalty
Summary
The facility failed to report in a timely manner an allegation of injury of unknown source for one resident with behavioral disturbance and dementia. The resident was found with a bruise to the left eye, and staff were unable to determine how the injury occurred, nor could the resident explain the incident. A CNA observed the bruise and reported it to an LPN, but the incident was not reported to the State Survey Agency as required. The Director of Nursing confirmed that the incident met the criteria for non-compliance due to the delay in reporting.
Failure to Provide Discharge Plan for Resident
Penalty
Summary
The facility failed to provide a discharge plan for one of three residents reviewed for discharge planning. Review of the clinical record for this resident showed no evidence of a discharge plan, and a notification in the record indicated the discharge plan was overdue by 16 days. The resident's care plan did not address discharge preferences, and care conference notes also lacked documentation of a discharge plan. During interviews, the Social Services Coordinator acknowledged that the discharge plan should have been completed, and the Director of Nursing Services stated she was not familiar with the discharge planning procedure, noting that it was the responsibility of Social Services to complete the discharge plan.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete timely Minimum Data Set (MDS) assessments for two residents. One resident, admitted with a fractured femur and osteoarthritis, had an admission MDS assessment that was still in progress and overdue by 15 days. Another resident, admitted with a pressure ulcer and chronic kidney disease, had an annual MDS assessment that was also in progress and overdue by 15 days. Staff interviews confirmed that the MDS Coordinator was behind on assessments and that MDS assessments are expected to be completed in a timely manner.
Failure to Timely Update Care Plan After Resident Aggression
Penalty
Summary
The facility failed to update the care plan for a resident with dementia following a reported incident of agitation and subsequent physical aggression. The resident was admitted with a diagnosis of dementia and was involved in an incident where the care plan was supposed to be revised to include an intervention to keep the resident further than an arm's length away from others when agitated. Although this intervention was identified after a facility reported incident, the care plan was not updated until after a second incident of physical aggression occurred. The Director of Nursing Services acknowledged that the care plan should have been updated within five days of the initial incident but was not revised in a timely manner.
Failure to Provide Sufficient Nursing Staff Resulting in Prolonged Call Light Wait Times
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of two residents during random observations. One resident, admitted with chronic kidney disease and epilepsy and assessed as cognitively intact, experienced a call light wait time of 47 minutes, as observed on the call light monitor. The resident confirmed that call light wait times were sometimes long, and a CNA reported being occupied with another resident's care during the delay. The CNA also noted that staff no longer had access to communication devices previously used to coordinate care. The Director of Nursing Services acknowledged that the wait time was too long. Another resident, admitted with anxiety and chronic pain and also cognitively intact, had a call light wait time of 40 minutes. The CNA assigned to this resident was working in the dining room during the delay, and the Director of Nursing Services confirmed this wait time was also excessive.
Incomplete Discharge Summaries for Residents
Penalty
Summary
The facility failed to complete comprehensive discharge summaries for three residents, which included a final summary of their status at the time of discharge. This deficiency was identified during interviews and record reviews. Resident 2, admitted in July 2024 with diabetes, had a discharge summary dated August 28, 2024, that did not include all necessary items consistent with their most recent comprehensive assessment. Missing information included details on functional abilities, urinary incontinence, psychosocial well-being, nutritional status, dental care, pressure ulcers, and pain. Similarly, Resident 4, admitted in July 2024 with heart failure, and Resident 5, admitted in June 2018 with dementia, also had incomplete discharge summaries. The discharge summaries for these residents, dated September 4, 2024, and August 26, 2024, respectively, lacked comprehensive details from their most recent assessments. These omissions were acknowledged by Staff 1 (DNS) during an interview on October 9, 2024, confirming that the discharge summaries did not provide a complete summary of the residents' final status upon discharge.
Improper Storage and Labeling of Medications and Biologicals
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and biologicals, which was identified during an audit of the South Hall treatment cart and the medication and biologicals refrigerator. An open vial of Insulin Glargine was found in the treatment cart with a date indicating it was over 28 days old, which should have been discarded. This was confirmed by a registered nurse (RN) during the audit. Additionally, an audit of the medication and biologicals refrigerator revealed an open and undated multi-dose vial of tuberculin solution and multiple closed vials of Spikevax (COVID-19 vaccine) with an expired date. A licensed practical nurse (LPN) verified the absence of an open date on the tuberculin vial and disposed of it in the sharps container. The expired Spikevax vials were acknowledged, with the facility awaiting a pharmacy exchange for viable vaccines. The RNCM stated that the expectation was for all medications to have an open date and for expired medications to be discarded appropriately.
Medication and Care Deficiencies in LTC Facility
Penalty
Summary
The facility failed to follow physician orders and provide timely care for several residents, leading to multiple deficiencies. One resident, admitted with cancer, had their bed rails removed without family notification, which were not transferred to a new bed. Another resident, admitted with paralysis, experienced delayed bowel care and inconsistent administration of pain medication, with staff failing to document or provide additional interventions when initial treatments were ineffective. A resident with alcohol use issues consumed more alcohol than permitted during an outing, as staff failed to supervise adequately and did not report the excess consumption to the facility upon return. Another resident received the wrong medication due to a discrepancy in the Medication Administration Record and Narcotics Log, although no adverse effects were reported. Additionally, several residents experienced delays in receiving their scheduled medications, with staff citing high resident acuity and workload as reasons for the delays. The report highlights systemic issues in medication administration and care delivery, with multiple instances of late or missed medications for residents with various medical conditions, including diabetes, chronic obstructive pulmonary disease, and epilepsy. Staff acknowledged the challenges in meeting scheduled medication times, and residents expressed dissatisfaction with the delays, indicating a need for improved processes and staffing to ensure timely and accurate care.
Failure to Obtain Consent for Influenza Vaccination
Penalty
Summary
The facility failed to obtain consent for an influenza vaccination for one resident, who was part of a sample of five residents reviewed for immunizations. The resident, admitted in October 2023 with a diagnosis of diabetes, was cognitively intact as indicated by a quarterly MDS assessment. A review of the resident's immunization record showed that the influenza vaccine was administered in December 2023. However, upon reviewing the medical record, there was no evidence of a signed consent for the vaccine. The Director of Nursing Services confirmed the absence of the signed consent and acknowledged that consent should have been obtained prior to administering the vaccine.
Failure to Notify Emergency Contacts and Physician
Penalty
Summary
The facility failed to notify a resident's emergency contacts and physician in two separate incidents, leading to deficiencies in communication and care. Resident 18, who was admitted to the facility in 2010 with a diagnosis of delayed stomach and bowel emptying, was transported to the hospital for abdominal pain, nausea, vomiting, and uncontrolled diarrhea. Despite being cognitively intact, as indicated by a quarterly MDS, Resident 18's emergency contacts were not informed of the hospitalization, as confirmed by both the resident and Staff 3 (RNCM). In another incident, Resident 47, who was admitted in July 2024 with paralysis following spinal surgery, experienced a change in condition when a small lump was identified above the surgical incision after reporting a popping sensation in the back. Although the family was informed and planned to contact the spinal surgeon, the facility staff did not notify the resident's physician about the lump. This oversight was acknowledged by Staff 2 (DNS) and Staff 3 (RNCM) during an assessment of the resident's spine.
Failure to Initiate Grievance Process for Missing Personal Property
Penalty
Summary
The facility failed to initiate a grievance process for a resident who was cognitively intact and had been admitted with diagnoses including diabetes. The resident reported that her/his cell phone was stolen a couple of months ago, resulting in a personal expense of $300 to replace it. Despite informing the facility's social services staff about the incident, no grievance form was filled out by either the resident or the staff member. The staff member acknowledged that this situation should have been treated as a grievance and required a formal grievance form and investigation.
Failure to Provide Bed Hold Policy During Hospitalization
Penalty
Summary
The facility failed to ensure that a resident received a bed hold policy during hospitalization, which is a requirement to inform residents of their rights to return to the facility. This deficiency was identified for one of the two sampled residents reviewed for hospitalization. Resident 18, who was admitted to the facility in 2018 with a diagnosis of delayed emptying of the stomach and intestines, was hospitalized on multiple occasions between October 2023 and August 2024. However, the progress notes did not indicate that Resident 18 or their emergency contacts were provided with a bed hold policy during these hospitalizations. On August 29, 2024, Staff 4 from Social Services stated that if she was present when a resident was discharged to the hospital, she ensured the resident or their representative received a bed hold policy. However, if the discharge occurred after hours or on weekends, the nursing staff was responsible for providing the policy. It was confirmed that Resident 18 was not provided with bed hold policies at the time of their hospitalizations.
Failure to Implement Baseline Care Plan for Spinal Precautions
Penalty
Summary
The facility failed to develop a baseline care plan for a resident who was admitted with a diagnosis of paralysis after spinal surgery. The baseline care plan, initiated several days after admission, did not include necessary precautions such as log-rolling and spinal precautions to prevent twisting of the spine. These precautions were only added to the care plan over a week later, following a therapy document that indicated the need for two staff to assist with bed mobility and ensure no leg movement. Despite the care plan update, the resident reported that staff did not follow the therapy directions for turning. Interviews with staff revealed that the necessary spinal precautions were not communicated effectively, as they were not included in the initial baseline care plan. Staff members acknowledged that the information was typically provided verbally by the nurse upon admission and added to the care plan within 24 hours, but in this case, the precautions were not documented until much later.
Failure in Safe Discharge Planning for Resident with Burn Wounds
Penalty
Summary
The facility failed to ensure safe discharge planning services for a resident who was admitted with third-degree burns to the left chest, abdomen, and thigh. Upon discharge, the resident was sent home with orders for home health and daily wound care. However, the home health services did not visit the resident before they were readmitted to the hospital due to concerns of wound infection and inability to self-care. The resident's burn wounds were found to be infected, requiring intravenous antibiotics. Interviews with facility staff revealed that although home health was ordered, they did not have time to see the resident before the hospital readmission. Additionally, there was no evidence of wound care training provided to the resident or their roommate, who was supposed to assist with wound care. The resident reported being discharged by mistake, as they were unable to perform wound care independently and had no family or friends to assist. The facility did not discuss or train the resident on wound care prior to discharge.
Failure to Assist Resident with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident with severe cognitive deficits, placing the resident at risk for unmet needs. The resident, admitted with a diagnosis of diabetes, was observed with dirty hair and jagged fingernails, indicating a lack of proper hygiene care. Documentation revealed that the resident did not receive scheduled showers or bathing on multiple occasions, with no evidence of refusal documented for several missed dates. Staff acknowledged the resident should have received showers twice a week and confirmed the absence of documentation for refusals on specific dates.
Failure to Assist Residents in Obtaining Prescription Glasses
Penalty
Summary
The facility failed to assist two residents in obtaining prescription glasses, which placed them at risk for impaired vision. Resident 18, who was admitted in October 2018 with bowel and stomach dysfunction, reported blurred distant vision during an eye exam in June 2024 and received a new prescription. Despite being cognitively intact, Resident 18 stated in August 2024 that they had not received the new glasses. Staff members from Social Services were unaware of the new prescription and did not have the after-visit summary, indicating a lack of follow-up on the resident's vision care needs. Similarly, Resident 3, admitted in March 2023 with diabetes, experienced a delay in receiving prescription glasses. Progress notes from July 2024 indicated that Resident 3 inquired about the status of their glasses, but there was no evidence of staff follow-up in the clinical record. In August 2024, Resident 3 reported seeing an ophthalmologist six weeks prior and was told the glasses would take about three weeks to arrive, yet they had not been received. Staff acknowledged awareness of the appointment and provided an invoice for the glasses dated June 2024, but the order had not been completed through the insurance provider.
Failure to Provide Necessary Splint for Resident
Penalty
Summary
The facility failed to provide a necessary splint for a resident with a right finger contracture, which was identified as a deficiency. The resident, admitted in March 2010 with a diagnosis of cancer, had an occupational therapy treatment encounter on May 9, 2024, where measurements for a right finger splint were obtained. However, the care plan last revised on July 5, 2024, did not include the requirement for a right finger splint. A physician appointment on July 24, 2024, noted the resident's right finger swelling and redness, and a referral for a finger splint was made. Despite these assessments and referrals, the resident was observed without a finger splint on August 27, 2024. Interviews with staff revealed a lack of awareness and documentation regarding the need for the splint. Staff 4, responsible for making appointments for referrals, was unaware of the need for a hand therapist or splint. Staff 15 confirmed that a splint was ordered, but it was not included in the care plan. Other staff members, including CNAs and a CMA, reported never seeing or applying a splint to the resident's finger. The RNCM acknowledged that the splint was not on the care plan, despite having helped order one.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 5.13 percent error rate. This was based on observations, interviews, and record reviews. Specifically, there were two errors in 39 medication administration opportunities. One of the errors involved a resident with chronic pancreatitis and chronic obstructive pulmonary disease, who was admitted in August 2024. The resident's physician orders included Creon to be administered three times a day with meals and Advair Diskus to be administered twice a day. On August 28, 2024, a staff member administered the resident's medications after breakfast but failed to have the resident rinse and spit after using the Advair Diskus, as required. Additionally, the Creon was not administered at the provider-ordered time of 8:00 AM.
Failure to Ensure Resident Understanding of Arbitration Agreement
Penalty
Summary
The facility failed to ensure that a resident understood an arbitration agreement, which was a deficiency identified during a survey. Resident 47, who was admitted to the facility with a diagnosis of diabetes and was cognitively intact according to the admission MDS, signed an arbitration agreement shortly after admission. However, the resident later stated that they did not recall signing the agreement, attributing this to being heavily medicated at the time and not receiving any follow-up regarding the agreement. The Social Service Director, responsible for admission paperwork, including arbitration agreements, confirmed that she explained the agreement and its optional nature but did not follow up with residents after they signed, considering it a one-time task. This lack of follow-up contributed to the resident's lack of understanding of the arbitration agreement.
Resident Dignity and Self-Determination Compromised
Penalty
Summary
A deficiency was identified involving the dignity and self-determination of a resident diagnosed with post-surgical procedure paraplegia, who was admitted to the facility in July 2024. The resident, who was cognitively intact, reported feeling frustrated and afraid due to interactions with a CNA regarding the changing of bed sheets. On one occasion, the resident requested the CNA to change sheets that were wet from sweat, but the CNA initially insisted the sheets were not wet and did not need changing. The resident felt compelled to argue to receive care. Eventually, the CNA left the room, returned with another CNA, and the sheets were changed. The DNS confirmed that staff should honor such requests from residents, and the resident reported feeling that it took too long for staff to return and provide the requested care.
Violation of Resident Mail Privacy
Penalty
Summary
The facility failed to respect the privacy and confidentiality of a resident's personal mail. Resident 12, who was admitted to the facility with a diagnosis of diabetes and was cognitively intact, reported that a staff member opened a package addressed to them without permission. The incident occurred when a staff member, identified as Staff 5, opened the package after hearing a sound that suggested it contained supplements or medication. This action was acknowledged by Staff 5 as a violation of the resident's rights. Further interviews revealed that Staff 14, the Activity Director, confirmed the accidental opening of the package and emphasized that all mail addressed to residents should be delivered unopened. Staff 3, an RNCM, was unaware of the incident but stated that staff should never open a resident's mail, even if it is suspected to contain medication. Instead, staff could be present when the resident opens their mail. The failure to deliver the mail unopened compromised the resident's right to privacy and confidentiality.
Failure to Prevent Pressure Ulcers in Resident with Paralysis
Penalty
Summary
The facility failed to prevent the development of pressure ulcers in a resident who was admitted with paralysis after spinal surgery. Upon admission, the resident did not have any pressure ulcers, and a care plan was initiated to address the risk of pressure ulcer development. However, the care plan's interventions, which included educating the resident and family on positioning requirements, were not consistently implemented. Progress notes from late July to early August indicate that the resident was assisted with turning and bed mobility, but the frequency of these actions was not documented. Additionally, there were several instances where no education was provided to the resident or family, despite the resident's reluctance to move due to incision pain. By early August, the resident developed a deep tissue injury on the sacral area, which was identified as a skin impairment with a moisture component. Interviews with staff and the resident's spouse revealed that the resident was not consistently turned every two hours, as required by standard care practices. Staff members acknowledged the challenges in adhering to the turning schedule due to time constraints and the resident's preference to remain on their back with the head of the bed elevated, which increased pressure on the coccyx region. The lack of consistent turning and education contributed to the development of the pressure ulcer.
Inadequate Supervision During Resident Outing Involving Alcohol
Penalty
Summary
The facility failed to provide adequate supervision during an outing involving alcohol for a resident with a history of alcohol use and moderate cognitive impairment. The resident was allowed to consume more alcohol than the physician-ordered limit of 12 ounces of beer. During the outing, two staff members, a Staffing Coordinator and an HR staff, were responsible for supervising the resident. However, they were unaware that the resident consumed additional beers beyond what was initially provided. The resident's condition changed upon returning to the facility, showing signs of fatigue, decreased responsiveness, and abnormal vital signs, prompting a call to EMTs. The investigation revealed that the resident consumed three and a half 12-ounce beers, exceeding the physician's order. The staff members involved did not inform the facility's nurse about the actual amount of alcohol consumed by the resident. Additionally, the staff allowed the resident to be unsupervised on the riverbank with a non-staff member, who provided the resident with more beer. This lack of supervision and communication led to a failure in ensuring the resident's safety during the outing, as evidenced by the resident's altered condition upon return.
Latest citations in Oregon
A resident with acute respiratory failure and heart failure had a documented Full Code status and a POLST specifying Attempt Resuscitation/CPR and Full Treatment. During night rounds, two CNAs found the resident not breathing, cool to the touch, with yellow skin and no pulse, but did not initiate CPR or call a code blue, instead going to notify an LPN. The LPN assessed the resident, confirmed absence of vital signs, noted the body was cold with mottling and no rigor mortis, and contacted the DNS, physician, and 911 for the coroner’s number, but did not start CPR or activate a code blue. No lifesaving measures were attempted despite facility policy requiring CPR for unresponsive residents without a valid DNR and the resident’s clearly documented full code status, leading surveyors to cite Immediate Jeopardy and substandard quality of care.
A resident with respiratory failure and pneumonia, who was Full Code and not on hospice, was found during routine rounds and suspected to be deceased. Nursing staff assessed the resident, noted there was no rigor mortis, confirmed death, and did not initiate a code blue or any resuscitation efforts despite the resident’s Full Code status. The facility later treated this as a potential neglect incident but did not report it to the State Agency within the required two-hour timeframe, as confirmed by the regional QA director.
A resident with chronic pain and a left below-knee amputation, who required supervision or touching assistance with ADLs, was discharged after returning from an outing shortly after midnight. Although discharge instructions noted the need for assistance and assistive devices, there was no documentation of referrals for medical equipment or home health services. Facility staff documented that the resident was discharged because they were out past midnight and believed Medicare would not cover the stay, did not issue a NOMNC, and recorded the discharge as voluntary despite the resident later reporting they had been “kicked out” and were sleeping on a friend’s couch with difficulty getting around. Staff interviews revealed no financial issues and indicated the resident had originally been scheduled for discharge at a later date.
A resident with a hip fracture and anxiety reported to social services that a CNA had been rough, told the resident to take themself to the bathroom, and instructed them not to get out of bed until a specified early morning time. The allegation was received by facility staff in the late afternoon, but the incident report was not submitted to the State Agency until the following day, exceeding the required 2-hour reporting timeframe acknowledged by the DNS. The deficiency concerns this untimely reporting of an abuse allegation, despite the CNA’s denial of any abuse.
A resident with hemiplegia, previously evaluated as not appropriate to self-administer any medications, was found to have open tubes of antifungal cream, anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) stored in a bedside drawer. Record review showed there were no MD orders for several of these topical products and no order permitting self-administration. An RN case manager confirmed the absence of orders, and the resident reported self-administering the medications, demonstrating a failure to ensure medications were administered only as ordered and in accordance with the resident’s assessed ability.
A resident with hemiplegia, previously evaluated as not appropriate to self-administer medications, was found with open containers of anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) in a bedside drawer. Record review showed no MD orders, no documented indication for use, and no monitoring for these medications. An RN case manager confirmed there were no orders and that staff did not administer or monitor the creams, while the resident reported self-administering them.
The facility failed to investigate multiple staff-reported allegations that one cognitively intact, wheelchair-using resident engaged in sexually inappropriate behaviors toward three other residents with significant cognitive and neurological impairments. Staff reported finding a resident with a ripped brief, crying and resisting care, and suspected sexual contact; they also reported that the alleged aggressor tried to take another resident into a shower room for sexual acts, attempted to video and kiss that resident, and encouraged a third resident to remove their top while present with a phone. CNAs, social services, and other staff stated they informed the administrator, DNS, HR, and unit management about these incidents and behaviors, but the administrator acknowledged that no investigations were conducted, despite being aware of the reports.
A resident with multiple sclerosis, care planned as dependent on two staff and requiring a Hoyer lift for transfers, was instead transferred by a CNA using a stand-pivot method without the lift or a second staff member. The CNA reported she had not read the resident’s care plan and described performing the transfer by giving the resident a “giant bear hug” and making several attempts to move the resident from chair to bed. The resident reported right flank pain and stated the transfer caused three broken ribs, although an x-ray later showed no rib fractures or dislocation and no visible injury was noted.
A resident with multiple sclerosis was admitted with physician orders for PT and OT, but review of the clinical record showed no documentation that these therapies were ever provided. The resident reported not receiving any therapy since admission, and the Director of Rehabilitation confirmed that no therapy services had been delivered during this period despite active orders, resulting in a failure to provide ordered rehabilitative services.
A dependent resident with dementia and a history of stroke, identified on the MDS as requiring staff assistance for showers, did not consistently receive scheduled bathing, and one CNA falsely documented that bathing had been provided. CNA task reports showed missed or undocumented baths on scheduled days, and an internal investigation confirmed that a bath recorded as completed on one date had not actually occurred. Staff interviews indicated that if bathing was not documented it usually did not occur, and that scheduled bathing was expected to be provided by staff.
Failure to Initiate CPR for a Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide CPR in accordance with a resident’s documented full code status. The facility’s Emergency Procedure CPR policy, initiated in 2001, required staff trained in CPR to initiate resuscitation on unresponsive residents who were not breathing unless there was a valid DNR order or clear signs of irreversible death such as rigor mortis. The policy further specified that if a resident’s DNR status was unclear, CPR should be started and continued until a DNR was confirmed. Resident 3 had been admitted with diagnoses including acute respiratory failure and heart failure and had a care plan and POLST on file indicating Full Code/Attempt Resuscitation and Full Treatment, including use of intubation, advanced airway interventions, mechanical ventilation, and transfer to hospital or ICU if indicated. On the night of the incident, a CNA (Staff 5) documented last vital signs for the resident at approximately 10:45 PM, with oxygen saturation of 92% on one liter of oxygen. At 2:00 AM, the resident was observed sleeping, breathing, and with a dry brief. Around 4:00 AM, Staff 5 and another CNA (Staff 8) entered the resident’s room and observed that the resident was not breathing, had yellow skin color, was cool to the touch, and had no palpable pulse. Both CNAs concluded the resident was deceased and went to notify the LPN (Staff 4) instead of initiating CPR or calling a code blue, despite having recent CPR training and later stating that, in retrospect, they would have started CPR and called for a code blue. When Staff 4 (LPN) entered the room, she assessed the resident and found no pulse, blood pressure, or respirations, noted the body was cold, with some mottling on the lower legs, pale/yellowish skin color, and no rigor mortis. Staff 4 did not initiate a code blue or CPR and instead contacted the DNS (Staff 2) and the physician, and then called 911 to obtain the coroner’s phone number. No lifesaving measures were attempted by any staff, despite the resident’s documented full code status and the facility policy requiring CPR in the absence of a valid DNR or signs of irreversible death. The DNS later stated she expected staff to call a code blue immediately, start CPR, call 911, and verify the resident’s code status. Surveyors determined that the facility failed to provide CPR according to the resident’s code status, placing all residents with full code status at risk and constituting substandard quality of care, with the noncompliance cited as Immediate Jeopardy and Past Noncompliance.
Removal Plan
- Administrator, DNS and nursing staff would be re-educated on the code blue process, how to locate a resident's code status in PCC and the POLST on file, and the importance of following individual resident care plans and orders.
- Resident code status would be cross-referenced with the PCC order, POLST scanned in binder, care plan, and resident dashboard.
- DNS or designee would monitor resident code status preferences for new admissions/returning admissions from hospitalizations.
- DNS or designee would audit code status for all new admissions and readmissions from hospitalization or ED visits, and share audit results with the QAPI committee to ensure substantial compliance is maintained.
- DNS or designee would complete a mock code.
- DNS or designee would complete mock codes.
Failure to Timely Report Alleged Neglect Involving Lack of CPR for Full Code Resident
Penalty
Summary
The facility failed to timely report an allegation of potential neglect related to CPR to the State Agency for one resident. The resident was admitted in February 2026 with diagnoses including respiratory failure and pneumonia and had a Full Code status, was not on hospice, and therefore was to receive CPR if found unresponsive. According to the facility’s investigation dated six days after the resident’s death, staff found the resident during routine rounds and suspected the resident was deceased, notified the nurse, and the nurse confirmed the resident was deceased. The investigation documented that at the time of the nurse’s assessment the resident did not have rigor mortis, yet the nurse did not initiate a code blue or any resuscitation interventions despite the Full Code status. The incident, which occurred on an identified date, was not reported to the State Agency until a later identified date, and the Regional Director of Quality Assurance confirmed that the facility did not report the incident within the required two-hour timeline. This failure to timely report the allegation of potential neglect involving the lack of CPR initiation for a Full Code resident constituted the deficiency identified by surveyors.
Failure to Ensure Safe and Orderly Discharge After Late Return from Outing
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and orderly discharge for a resident who was admitted with chronic pain, a left below-knee amputation, and post-surgical aftercare needs. An admission MDS completed shortly after admission documented that the resident was cognitively intact but required supervision or touching assistance with toileting, transfers, and bathing. Discharge instructions indicated the resident was being discharged home and that the resident’s current physical status required assistance and assistive devices, yet there was no documentation of referrals for needed medical equipment or a home health referral. The facility’s records did not show that these services or equipment were arranged prior to discharge. On the night in question, a nursing note documented that the resident returned to the facility after an outing at 12:23 AM, after the facility had notified the police because the resident’s location was unknown. The resident reported having been out with friends and being unaware of any concern. A social services note stated that because the resident was out past midnight, the resident was discharged from the facility, and a NOMNC was not issued because the resident left prior to the scheduled discharge and on their own initiative. A discharge summary documented that discharge instructions were reviewed with the resident, who refused to sign and was leaving voluntarily, and the voluntary consent form included a handwritten statement that the resident refused to sign. Later, the resident stated they had been “kicked out” for coming back late and were sleeping on a friend’s couch, finding it difficult to get around. Staff interviews showed there were no financial issues documented, that staff believed Medicare would not cover the resident if out past midnight, and that the resident had been scheduled for discharge several days later, while a regional director later characterized the situation as a clerical error and confirmed a normal discharge should have been completed.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to timely report an allegation of abuse to the State Agency after a resident reported that a CNA had been rough and verbally directive with them. The resident, who had been admitted with diagnoses including a hip fracture and anxiety, stated that the CNA was “kind of rough,” told the resident to take themself to the bathroom, and instructed the resident not to get out of bed until 6:00 AM. The resident reported this allegation of abuse involving the CNA to the social services staff member at 4:00 PM on 1/29/26. According to the facility’s investigation documentation, the allegation was received by staff at 4:00 PM on 1/29/26, and the Facility Reported Incident form was not received by the State Agency until 2:13 PM on 1/30/26. The DNS acknowledged that the facility became aware of the allegation at 4:00 PM on 1/29/26 and that it should have been reported to the State Agency within two hours but was not. The CNA denied abusing the resident or any resident, but the deficiency centers on the delay in reporting the allegation to the State Agency within the required timeframe.
Failure to Prevent Unauthorized Self-Administration of Non-Prescribed Medications
Penalty
Summary
Surveyors identified that a resident was self-administering non-prescribed topical medications despite a documented determination that they were not appropriate to self-administer any medications. The resident, admitted with hemiplegia, had a Self-Medication Administration Evaluation dated 11/13/25 indicating they were not appropriate to self-administer medications. During an observation on 3/19/26 at 7:50 AM with a RN case manager, open tubes of antifungal cream, anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) were found in the resident’s bedside table drawer. Review of the clinical record showed there were no physician orders for the anti-itch cream, hydrocortisone cream, or DMSO, and the resident did not have an order to self-administer any medications. The RN case manager confirmed the lack of orders for these medications, and at 8:10 AM the resident stated they did self-administer the medications found in their room. This constituted a failure by the facility to ensure the resident did not self-administer non-prescribed medications and to provide treatment and care according to physician orders and the resident’s evaluated ability to self-administer medications.
Unmonitored Self-Administration of Topical Medications Without Physician Orders
Penalty
Summary
The facility failed to ensure a resident’s drug regimen was free from unnecessary drugs by not providing adequate monitoring, indication for use, or physician orders for multiple medications. A resident admitted with hemiplegia in May 2024 had a self-medication administration evaluation dated 11/13/25 indicating they were not appropriate to self-administer any medications. During an observation on 3/19/26, an RN case manager found an open tube of anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) in the resident’s bedside table drawer. Record review showed no physician orders, no documented indication for use, and no monitoring for these medications. The RN case manager confirmed the resident did not have orders for the anti-itch cream, hydrocortisone cream, or DMSO, and that staff did not administer or monitor these medications. The resident stated they self-administered the medications found in their room, despite the prior evaluation determining they were not appropriate to self-administer any medications.
Failure to Investigate Multiple Allegations of Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to investigate multiple allegations of sexual abuse involving three residents. Resident 102, who had cognitive loss equivalent to a young child, legal blindness, and was non-verbal, was reportedly found with a ripped brief, crying, and resisting a brief change. Staff reported concerns that another resident, Resident 105, had performed or attempted to perform sexual acts on Resident 102. Staff members, including CNAs and social services, stated they informed facility management, including the Administrator and DNS, about the torn brief, Resident 102’s distress, and concerns that Resident 105 was being sexually inappropriate with multiple residents. Despite these reports and discussions in morning meetings, the Administrator acknowledged that no investigation was completed, believing the incident was based on staff assumptions. The facility also failed to investigate allegations involving Resident 103, who had Alzheimer’s disease and Parkinson’s disease. Staff reported that Resident 105 attempted to take Resident 103 into a shower room to perform sexual acts, and that a staff member intervened. The complainant later spoke with Resident 103, who stated that Resident 105 was “sick” and made bad comments. Other staff reported to human resources, the DNS, and the Administrator that Resident 105 attempted to take a resident into a shower room to unclothe the resident, and that Resident 105 attempted to video Resident 103, expressed a desire to kiss Resident 103, and get the resident into a shower room. The Social Service Director confirmed she reported these concerns to the Administrator, who stated he was aware of the incident but that no investigation was completed. A third failure to investigate involved Resident 108, who had Huntington’s disease and dementia. A staff member reported observing Resident 105 telling Resident 108 to take off their shirt and gesturing for them to do so, and stated they completed a written statement and gave it to the unit manager. Another CNA reported hearing that Resident 105 and other residents were laughing and encouraging Resident 108 to remove their top, and also reported observing Resident 105 rubbing other residents’ backs more physically than appropriate. Social services reported being told that Resident 108 was removing their top while Resident 105 was in the dining room with a phone, and that Resident 105 admitted to the behavior but described it as innocent. The Administrator stated he was aware of Resident 108 removing their shirt while Resident 105 was present, yet confirmed that no investigation was completed for this incident. These failures to investigate led surveyors to determine that the facility did not respond appropriately to alleged violations of sexual abuse for the three residents.
Removal Plan
- Residents 102, 103, and 108 received head-to-toe skin assessments completed by RCMs with no observed findings.
- Resident 105 was placed on one-to-one observations pending investigations.
- Staff 1 (Administrator) and Staff 2 (DNS) were re-educated on the facility's abuse policy, reporting, and thorough investigations.
- Social Services will interview all interviewable residents regarding abuse.
- Nurses will complete a head-to-toe assessment on all non-interviewable residents.
- All staff, including agency staff, will be re-educated on the facility's abuse policy and reporting.
Failure to Follow Care-Planned Hoyer Lift Transfer Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow a resident’s care plan interventions for transfers, resulting in a transfer being performed without required equipment and assistance. A resident admitted in February 2026 with multiple sclerosis had a 2/25/26 ADL care plan indicating the resident was dependent on two staff members for transfers and required use of a Hoyer (mechanical) lift. Despite this, on 2/28/26 a CNA (Staff 3) performed a stand-pivot transfer without the Hoyer lift and without a second staff member. The resident later reported that Staff 3 gave a “giant bear hug” and made several attempts to transfer the resident from chair to bed, after which the resident reported right flank pain and stated the transfer caused three broken ribs. An x-ray on 3/10/26 showed no rib fractures or dislocation, and the resident was assessed to have no visible injury. During interview, Staff 3 confirmed she had completed a stand-pivot transfer with the resident and acknowledged she had not read the resident’s care plan, and the Administrator confirmed that the resident had been care planned for a two-person Hoyer lift transfer at the time of the incident.
Failure to Provide Ordered Rehabilitative Services
Penalty
Summary
The facility failed to provide ordered rehabilitative services to a resident with multiple sclerosis. The resident was admitted in February 2026 with admission orders dated 2/24/26 for both physical therapy and occupational therapy. Review of the resident’s clinical record showed no documented evidence that any therapy services were provided as ordered. In an interview on 3/11/26 at 10:58 AM, the resident reported not having received any therapy since admission. During a separate interview on 3/11/26 at 10:40 AM, the Director of Rehabilitation confirmed that the resident had not received any therapy services from the date of admission through 3/11/26, despite the existing orders for physical and occupational therapy. This failure to implement the physician’s orders for rehabilitative services for this resident placed the resident at risk for a decline in range of motion.
Failure to Provide and Accurately Document Scheduled Bathing for a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a dependent resident received required assistance with activities of daily living (ADLs), specifically bathing, and inaccurate documentation that bathing had been provided. The resident, admitted in 10/2025 with dementia and stroke, had a 10/21/25 admission MDS indicating severe cognitive impairment and dependence on staff for showers. The facility’s 12/2025 CNA task report showed the resident was scheduled for bathing on day shift on Wednesdays and Sundays. On 12/24/25, the task report was blank for bathing, and on 12/28/25, the report documented that the resident received bathing and was dependent on staff for assistance. However, a 12/29/25 facility investigation determined the resident did not receive a bath on 12/28/25 and that it had been falsely documented that bathing occurred. A Facility Reported Incident form dated 12/31/25 further documented that on 12/28/25, a CNA (Staff 5) noted providing bathing to the resident but did not provide any type of bathing. Additional record review showed that the resident’s 3/2026 CNA task report contained no documentation that any type of bathing was provided on 3/11/26. Attempts to contact Staff 5 on 3/16/26 and 3/17/26 were unsuccessful. During interviews, another CNA (Staff 7) stated that on 12/28/25 she observed Staff 5 lay the resident down and, when she asked about bathing, Staff 5 said she would complete the resident’s bathing in the evening; Staff 7 stated she could not perform the resident’s bathing in the evening because she moved to a different hall on evening shift. Another CNA (Staff 21) stated that usually if bathing was not documented in the resident’s record, bathing did not occur. The Regional Nurse (Staff 31) stated that staff should provide scheduled bathing to residents.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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