Evan Terrace Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Mcminnville, Oregon.
- Location
- 421 Se Evans Street, Mcminnville, Oregon 97128
- CMS Provider Number
- 385225
- Inspections on file
- 30
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Evan Terrace Post Acute during CMS and state inspections, most recent first.
A resident was admitted with an indwelling urinary catheter noted on the admission evaluation, but there was no corresponding catheter order or documented clinical indication in the medical record. An LPN/RCM later confirmed that the resident had been admitted with the catheter in place without any documented reason for its use, constituting a failure to ensure appropriate catheter care and prevention of urinary tract infections.
A resident with a feeding tube received enteral nutrition at a rate much higher than prescribed, as staff left the feeding pump running at 300 ml/hr instead of the ordered 66 ml/hr. The error was discovered when an LPN observed formula bubbling from the resident's tracheostomy site, and staff interviews confirmed the deviation from physician orders.
A resident with dementia and a leg fracture developed multiple facility-acquired pressure ulcers due to the facility's failure to complete baseline and ongoing wound assessments, maintain accurate documentation, and obtain timely wound clinic notes. Staff and leadership were unable to recall or accurately report the resident's condition, resulting in discharge with several unassessed and misdocumented pressure ulcers.
Two residents did not receive medications as ordered by their physicians, including incorrect dosing of levothyroxine for a resident with hypothyroidism and missed insulin doses for a resident with diabetes and neuropathy. Errors included both over-administration and omission of prescribed medications, with staff and administration made aware of the incidents.
A resident with a tracheostomy was transferred to the hospital after improper setup of humidified oxygen was observed. Multiple staff, including agency LPNs and a CMA, reported not receiving tracheostomy training, and the physician assistant noted inconsistent staff knowledge. Facility leadership could not provide documentation of staff training for tracheostomy care.
The facility did not ensure that pharmacist recommendations for medication regimen reviews were acted upon for several residents, including those with dementia, heart conditions, depression, PTSD, and post-surgical needs. Pharmacy recommendations for gradual dose reductions, medication simplification, and laboratory monitoring were repeatedly unaddressed or not communicated to providers, as confirmed by staff interviews and record reviews.
Staff failed to consistently follow infection control protocols for two residents on Enhanced Barrier and droplet precautions, including not wearing required gowns, masks, or eye protection, and not performing hand hygiene. Staff demonstrated a lack of awareness and understanding of the required PPE, and necessary supplies were not always available at the point of care.
Allegations of sexual abuse involving three residents, including one with moderate cognitive impairment and two with no cognitive impairment, were not reported to the State Agency within the required timeframe. Facility management and the Social Services Director were aware of the allegations but did not ensure they were reported or investigated as required.
The facility did not investigate multiple allegations of sexual, physical, and verbal abuse involving several residents, including reports of being hit, sworn at, and inappropriately touched by staff or other residents. Despite staff and management being aware of these allegations, no comprehensive investigations were conducted or documented.
A resident with dementia and behavioral disturbances was administered divalproex sodium, used as an antipsychotic, without documented informed consent. While consent was obtained for other psychotropic medications, there was no signed consent for divalproex sodium, and facility staff confirmed this omission.
A resident with a history of stroke and depression, who was cognitively intact, requested a room change because a roommate's loud television disrupted sleep. The request was reported to the Social Services Director, but no follow-up occurred as staff prioritized discharge planning. The administrator was unaware of the request, and the resident continued to experience noise issues despite using headphones.
A resident with a history of spinal abscess and paralysis had a PRN order for Prochlorperazine that was not reviewed or evaluated by a physician within the required 14-day period. An LPN confirmed that the order continued beyond the allowed timeframe without the necessary assessment or rationale from the prescriber.
A resident with a history of trauma and a diagnosis of schizophrenia, who was cognitively intact, expressed a preference for female caregivers due to discomfort with male staff. Although this preference was known to staff and documented in assessments, it was not included in the resident's care plan.
A resident with diabetes and multiple ulcers did not receive timely wound care due to the facility's failure to obtain and implement updated treatment orders from an outside wound clinic. Staff interviews revealed inconsistent processes for verifying and carrying out new orders, communication challenges with the clinic, and a lack of coordination among providers.
A resident with a feeding tube did not receive appropriate care when staff failed to change the tube feeding bag and tubing daily as ordered, despite documentation indicating it was done. Staff confirmed the missed changes and acknowledged the risks, and the DON verified that daily changes were required.
A resident with severe dementia and behavioral disturbances exhibited frequent aggressive and resistive behaviors, but the care plan was not comprehensively revised to address identified triggers or incorporate detailed staff observations, particularly regarding the calming effect of the resident's spouse and specific behavioral patterns. Staff interviews confirmed the need for a more individualized, resident-centered approach.
A resident with multiple fractures did not receive prescribed physical therapy after returning from a physician visit, as the therapy order was not entered into the health record or communicated to therapy staff. As a result, the resident was not scheduled for the required therapy sessions.
A resident with complex medical needs did not have their feeding tube bag and tubing changed daily as ordered, despite documentation by LPNs indicating the task was completed. Observations and staff interviews confirmed the bag was not changed for several days, resulting in inaccurate medical records.
Two residents experienced falls that were not promptly or thoroughly investigated. In both cases, required witness statements were not collected, and care plans were not updated in a timely manner to address fall prevention. Staff acknowledged delays and incomplete investigations, which did not align with facility policy.
The facility did not make state survey inspection results accessible, as eight residents were unaware of their location and no postings or signage were found throughout the building. The administrator confirmed the absence of these results for both residents and visitors.
The facility did not consistently document registered nurse staffing information on daily reports, with 10 days missing required data during the review period. The Administrator confirmed the incomplete staffing forms.
A facility failed to implement a physician's order for diabetic management for a resident with diabetes and a UTI. The order to check the resident's CBG every morning, at bedtime, and as needed was delayed by seven days, as acknowledged by staff.
A resident with multiple fractures did not receive the prescribed physical therapy five times a week due to staffing issues. The resident missed four therapy sessions, and the deficiency was acknowledged by both the physical therapist and the DNS.
The facility failed to update its Facility Assessment to reflect current ownership and staffing, leading to a deficiency in care for residents with tube feeding needs. The assessment was outdated, listing previous owners and staff, and there was no evidence of training for nursing staff on feeding tube care. Additionally, the facility lacked necessary feeding and NG tubes, as confirmed by the DNS.
The facility failed to ensure nursing staff were trained and competent in managing feeding and NG tubes, essential for residents requiring nutritional supplementation. Despite a meeting where NG tube training was reportedly presented, no documentation was available. The administrator confirmed the absence of training and competency records, and agency nurses received no additional training. The orientation checklist lacked tube feeding and NG tube training, highlighting inadequate training protocols.
The facility inadequately investigated allegations of abuse and neglect for three residents. A resident with dementia reported an intruder, but the investigation lacked thorough documentation and interviews. Another resident was unsafely discharged without follow-up care, and the investigation was incomplete. A third resident's concerns about a roommate and missed medications were not properly investigated, with the FRI submitted late.
The facility did not complete baseline care plans within the required timeframe for two residents, one with a liver transplant and diabetes, and another with dementia, stroke, and COPD. The delays, confirmed by the DNS, were 32 and 21 days post-admission, respectively.
The facility failed to ensure proper discharge planning for two residents, leading to potential health risks. One resident with dementia and wound care needs was discharged without a provider or necessary medical equipment, resulting in an emergency department visit. Another resident with acute respiratory failure was discharged without confirmed home health services, causing a 15-day delay in care.
The facility failed to follow physician orders and notify physicians of omitted medications for three residents, leading to unmet medication and treatment needs. A resident with diabetes and sepsis missed several medications and treatments, while another with a liver transplant and diabetes experienced multiple medication administration failures and delayed wound care. A third resident with cirrhosis and a fractured femur missed doses of lactulose, with delayed provider notification.
A facility failed to provide proper care for a resident with an NG feeding tube, resulting in multiple hospital transfers due to clogged tubes. The resident, with chronic hepatic failure and dysphagia, did not receive necessary nutrition on several occasions. Staff lacked training and competencies for NG tube management, and the facility did not supply necessary NG tube supplies.
Two residents experienced significant medication errors in the facility. A resident with a liver transplant missed doses of critical medications like midodrine and valganciclovir, and had late administrations of prednisone and tacrolimus. Another resident with alcoholic cirrhosis missed doses of lactulose, essential for managing hepatic encephalopathy. These errors were acknowledged by the DNS and Interim DNS.
The facility failed to ensure timely administration of medications for 12 of 15 sampled residents, leading to delays ranging from one to six hours. Staff members cited reasons such as being occupied with other residents and starting shifts late.
The facility failed to ensure sufficient staffing to meet resident care needs, resulting in delayed call light responses, incontinence episodes, and late medication administration. Observations and interviews revealed that residents waited up to two hours for assistance, and staff struggled to complete their duties due to short staffing and high-acuity residents.
The facility failed to ensure residents were free from unnecessary medications. One resident with end-stage renal disease received midodrine despite having a systolic blood pressure greater than 90 on 83 occasions. Another resident with diabetes received insulin lispro even when their CBG was below 120 on seven occasions. Staff acknowledged these discrepancies.
The facility failed to ensure proper labeling of insulin pens, maintain temperature logs for medication storage, and secure medication carts. Open insulin pens were found without open dates, temperature logs were incomplete, and medication carts were left unlocked and unattended, placing residents at risk.
A resident admitted with asthma and acute respiratory failure with hypoxia required continuous oxygen therapy, as indicated in admission orders and observed in daily use. However, the 4/5/24 Admission MDS inaccurately stated that the resident did not require oxygen. This error was confirmed by the Resident Care Manager.
The facility failed to ensure a written summary of a baseline care plan was reviewed and provided to a resident within 48 hours of admission. The resident, admitted with diabetes and kidney failure, did not have documentation indicating receipt or review of the baseline care plan. This was confirmed by a Resident Care Manager.
The facility failed to update a care plan for a resident with dementia and hypertension. The care plan required staff to wake the resident at 2:00 AM to void, but CNAs were unaware of this intervention and noted it did not fit the resident's current needs. The DNS confirmed the care plan was outdated.
A resident admitted with multiple pressure ulcers did not receive timely and appropriate wound care. The initial care plan lacked specific interventions, and staff were unaware of the resident's skin issues. Dressings were not changed as ordered, and comprehensive assessments were delayed, leading to worsening conditions.
The facility failed to ensure accurate medical records for a resident, leading to a risk of inaccurate treatment. The resident, who had dementia and hypertension, was documented as receiving pantoprazole at 5:20 AM but was found deceased at 7:15 AM. Police and coroner findings indicated the death occurred around midnight. A former employee admitted to administering the medication the night before and not checking on the resident for the rest of the shift. The administration time was confirmed to be documented incorrectly.
Lack of Documented Clinical Indication for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to ensure that an indwelling urinary catheter had a documented clinical indication for use for one resident. The resident was admitted in August 2025 with diagnoses including schizophrenia, and the admission evaluation dated 8/8/25 indicated the resident had an indwelling urinary catheter in place. However, the admission orders did not include any order for a urinary catheter, and review of the clinical record revealed no documented evidence supporting a clinical indication for the catheter’s use. On 3/16/26 at 9:16 AM, an LPN/Resident Care Manager confirmed that the resident had been admitted with an indwelling urinary catheter and that there was no indication documented for its use. This deficiency was cited under the requirement to provide appropriate care for residents who are continent or incontinent of bowel/bladder, including appropriate catheter care and care to prevent urinary tract infections, and it was noted that this failure placed residents at risk for infection.
Failure to Follow Physician Orders for Feeding Tube Administration
Penalty
Summary
A deficiency occurred when a resident with a feeding tube did not receive care in accordance with physician orders. The resident had a physician order for enteral feeding with Jevity 1.5 at a rate of 66 ml/hr for 18 hours daily, administered via pump. However, staff left the feeding tube running at a rate of approximately 300 ml/hr, significantly exceeding the prescribed rate. This error was discovered when staff observed feeding formula bubbling out of the resident's tracheostomy site. Multiple staff interviews confirmed that the feeding tube was set incorrectly and that the physician's orders were not followed.
Failure to Provide and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to provide pressure ulcer care consistent with professional standards of practice for one resident who was at risk for pressure ulcers and had a history of dementia and a right lower leg fracture. Upon admission, the resident had no open skin areas, but over the course of their stay, developed multiple facility-acquired pressure ulcers. The facility did not complete a baseline care plan addressing the resident's skin or risk for pressure ulcers upon admission, and subsequent care plans and assessments contained inaccurate or missing information regarding the presence, staging, and description of the pressure ulcers. There were numerous missing weekly wound assessments for each of the resident's pressure ulcers, and the facility did not document evaluation of the development of these ulcers to determine causative factors or assess the effectiveness of interventions. Additionally, the facility failed to obtain or request the resident's wound clinic notes in a timely manner, and the discharge MDS inaccurately reported the number of pressure ulcers present at discharge. Interviews with multiple staff members revealed that none could recall the resident in question, and facility leadership confirmed the inaccuracies and missing documentation related to the resident's pressure ulcers. These failures resulted in the resident being discharged with multiple unassessed and inaccurately documented pressure ulcers.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to follow physician orders for two residents regarding medication administration. For one resident with hypothyroidism and diabetes, a physician order for levothyroxine to be given once daily via feeding tube was incorrectly transcribed as three times daily. As a result, the resident received three doses on one day and two doses on the following day, instead of the prescribed single daily dose. The error was identified in the medical record and confirmed by a physician progress note, but the administrator provided no additional information when informed of the findings. For another resident with a history of above-the-knee amputation and diabetes with neuropathy, multiple doses of prescribed insulin lispro were missed over two consecutive days. The orders included both scheduled and sliding scale insulin doses, but documentation revealed that several doses were not administered as ordered. An LPN discovered the missed doses and reported the issue to the Director of Nursing Services. The administrator was also informed of these findings and did not provide further information.
Failure to Provide Tracheostomy Training for Staff
Penalty
Summary
The facility failed to implement and maintain an effective tracheostomy training program for staff caring for a resident with a tracheostomy. The resident, admitted with acute respiratory failure and a tracheostomy, was transferred to the hospital after an incident involving improper setup of humidified oxygen tubing and partially filled humidifier water, as documented by EMS. Staff interviews revealed that multiple staff members, including agency LPNs and a CMA, had not received tracheostomy training from the facility. One LPN reported not feeling qualified to care for a resident with a tracheostomy and relied on a CNA for guidance, while another staff member stated only one nurse was assigned to the resident, with no clear backup if that nurse was unavailable. Further, the physician assistant expressed uncertainty about the staff's competency in tracheostomy care, noting inconsistent answers from staff regarding the resident's care. The administrator and director of nursing services were unable to provide documentation showing that staff had been trained to care for residents with tracheostomies. These findings indicate that the facility did not ensure staff were adequately trained or documented as trained to provide appropriate care for a resident with a tracheostomy.
Failure to Act on Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to ensure that pharmacist recommendations regarding medication regimen reviews were considered and acted upon for four out of five sampled residents. According to the facility's policy, a licensed pharmacist is required to review each resident's medication regimen monthly and report any irregularities, which must then be addressed in a timely manner. However, multiple instances were identified where pharmacy recommendations were either not communicated to the physician or not acted upon, resulting in repeated recommendations and lack of documented follow-up. For one resident with dementia and behavioral disturbances, pharmacy recommendations for a gradual dose reduction (GDR) of psychotropic medications were repeatedly made over several months without evidence of action or discussion by the interdisciplinary team. Another resident with chronic heart conditions had pharmacy recommendations for periodic potassium assessments that were not followed up or documented in the clinical record. A third resident with depression and PTSD had multiple pharmacy recommendations to simplify opioid orders and initiate GDRs for psychotropic medications, but there was no physician response or evidence that these recommendations were sent to the physician. Lastly, a resident admitted for surgical aftercare had several pharmacy recommendations regarding pain and PRN medication orders that were not implemented, with facility staff acknowledging that recommendations were not sent to providers during a period when the regular pharmacist was on leave. Interviews with facility staff confirmed that pharmacy recommendations were not consistently communicated to physicians or addressed as required by policy. The lack of timely response and follow-up on pharmacist recommendations placed residents at risk for unnecessary medications and unaddressed medication-related issues.
Failure to Follow Infection Control Protocols for Residents on Precautions
Penalty
Summary
The facility failed to follow proper infection control protocols for two residents with complex medical needs. One resident with multiple pressure ulcers, including a Stage 4 sacral ulcer, was placed on Enhanced Barrier Precautions (EBP) as indicated by signage outside the room. However, staff were observed entering the room and providing direct care while wearing gloves only, without donning the required gowns. Staff confirmed a lack of understanding regarding the need for gowns and noted the absence of gown supplies near the precaution signage, despite the care plan and CDC guidance requiring both gown and glove use for residents with wounds. Another resident with a tracheostomy, MRSA infection, and pneumonia was on droplet and enhanced standard precautions, as indicated by signage and the care plan. Multiple staff members, including LPNs and agency staff, were observed entering the resident's room without wearing masks or eye protection, and in some cases, without performing hand hygiene. Staff interviews revealed a lack of awareness of the required precautions and inconsistent use of personal protective equipment (PPE), even after being reminded of the protocols. The facility's infection preventionist and director of nursing confirmed that staff were expected to use appropriate PPE and educate visitors, but acknowledged that staff compliance was lacking.
Failure to Timely Report Allegations of Abuse to State Agency
Penalty
Summary
The facility failed to report allegations of abuse, including sexual abuse, to the State Agency within the required two-hour timeframe for three residents. One resident with Huntington's Disease and moderate cognitive impairment reported to a witness that a staff member fondled them, but there was no evidence the incident was reported to the facility or the State Agency, and no investigation was conducted. Staff interviews confirmed that management was aware of the allegation but did not initiate an investigation or report the incident as required. Two additional residents, both with no cognitive impairment, reported that an unidentified male caregiver had inappropriately touched their breasts. The Social Services Director was aware of these allegations and reported them to the Administrator for further investigation. However, record review and staff interviews confirmed that these allegations were not reported to the State Agency. The Administrator acknowledged awareness of the allegations but did not fulfill the reporting requirement.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to investigate allegations of sexual, physical, and verbal abuse for four of six sampled residents. In one case, a cognitively intact resident reported being hit and sworn at by another resident with severe cognitive impairment, and also reported a prior incident of being slapped. The administrator acknowledged being informed of the incident and speaking to a potential witness but did not document interviews or conduct a full investigation. Staff confirmed witnessing an altercation and reporting it to nursing staff, but no comprehensive investigation was initiated as required. In three additional cases, residents with varying levels of cognitive function reported allegations of sexual abuse by staff or unidentified caregivers. One resident reported to a complainant that a staff member fondled them, but there was no documentation or investigation of the allegation. Two other residents reported that a male caregiver had touched their breasts, and while the social services director was aware and reported the allegations to the administrator, no investigations were completed. Staff interviews confirmed knowledge of the allegations but no evidence of investigations was found in the records.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to obtain informed consent for the use of divalproex sodium, an anticonvulsant medication used as an antipsychotic, for a resident admitted with dementia with behavioral disturbances and convulsions. Documentation showed that while verbal consent was obtained for other psychotropic medications, divalproex sodium was not included. The resident's admission assessment indicated the use of psychotropic medications to manage agitation and aggressive behaviors, and subsequent interdisciplinary team review confirmed the administration of divalproex sodium. However, a review of the clinical record revealed no signed consent for this medication, and facility staff acknowledged that the required consent was not obtained.
Failure to Honor Resident Room Change Request Due to Noise
Penalty
Summary
A resident admitted with a history of stroke and depression, and assessed as cognitively intact, requested a room change due to the loud volume of a roommate's television, which disrupted sleep. The resident reported the issue to the Social Services Director, but no follow-up was provided, as the staff member was focused on discharge arrangements instead. Observations confirmed the television volume was loud during multiple visits, and the resident resorted to using headphones, which only partially alleviated the problem. The facility administrator was not made aware of the resident's request for a room change.
Failure to Review PRN Psychotropic Medication Orders Within Required Timeframe
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications. A resident admitted for surgical aftercare with diagnoses including spinal abscess and lower body paralysis had a PRN order for Prochlorperazine, a medication used to treat nausea and vomiting. Facility records showed that a letter was sent to the prescriber advising that the PRN Prochlorperazine required a direct examination and rationale every 14 days. However, there was no evidence in the resident's medical record that the physician reviewed, assessed, or evaluated the resident within the required 14-day period for the PRN antipsychotic. The LPN Resident Care Manager confirmed that the PRN order continued beyond 14 days without the necessary review and evaluation.
Failure to Address Resident's Gender Preference for Caregivers in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed all of a resident's needs, specifically omitting the resident's preference to receive care only from female caregivers. The resident, who was admitted with a diagnosis of schizophrenia and had a history of trauma related to rape and sexual assault, was found to be cognitively intact according to the BIMS assessment. Despite documentation in the social history assessment and direct statements from the resident expressing discomfort with male caregivers and a preference for female staff, the updated care plan did not reflect this preference. Staff interviews confirmed awareness of the resident's preference, but the care plan was not updated accordingly, resulting in the deficiency.
Failure to Implement and Communicate Wound Care Orders for Diabetic Ulcers
Penalty
Summary
The facility failed to obtain and implement treatment orders for a resident with diabetic ulcers, resulting in a lack of timely wound care. The resident, who had a history of diabetes and osteomyelitis, was admitted with multiple arterial and diabetic foot ulcers. Documentation showed that after returning from the wound clinic, new treatment orders were not consistently implemented or reflected in the Treatment Administration Record (TAR). The resident reported a preference for wound care at the clinic and noted that clinic orders were not always followed by the facility. Staff interviews revealed inconsistent processes for verifying and implementing new wound care orders after the resident's visits to the wound clinic. Communication challenges between the facility and the wound clinic were reported, with staff indicating that orders were sometimes requested but not received, and agency staff were not always aware of the procedures. The nurse practitioner did not coordinate communication between the resident's multiple providers, and the regional clinical director expected timely verification and implementation of wound care orders, which did not occur.
Failure to Change Tube Feeding Bag and Tubing as Ordered
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident with a feeding tube received appropriate care and services as required. The resident, who had multiple diagnoses including acute respiratory failure, pneumonia, stroke, and a tracheostomy, was admitted with orders for tube feeding using a specific formula and instructions to change the feeding bag and tubing daily at 4:00 PM. Despite these orders and best practice guidelines stating that open system tube feeding containers and tubing should be changed at least every 24 hours, observations revealed that the tube feeding bag in use was dated several days prior and had not been changed as required. Staff interviews confirmed that the tube feeding bag and tubing were not changed on multiple consecutive days, even though documentation indicated otherwise. Staff acknowledged awareness of the missed changes and described the associated risks, including bacterial growth and potential for gastrointestinal issues. The Director of Nursing Services also confirmed that the bag and tubing should have been changed daily according to orders and best practices.
Failure to Revise Dementia Care Plan Based on Resident Behaviors
Penalty
Summary
The facility failed to comprehensively assess and revise the care plan for a resident diagnosed with dementia and behavioral disturbances. The resident, admitted with severe cognitive impairment as indicated by a BIMS score of 6, exhibited frequent behaviors such as kicking, yelling, rejecting care, and threatening or grabbing others on 16 out of 32 days. The care plan was revised to instruct staff to analyze and document triggers and de-escalation strategies, and to engage calmly with the resident before providing care. However, no additional behavior triggers were identified in the care plan despite ongoing behavioral incidents. Staff interviews and observations revealed that the resident's behaviors were influenced by the presence or absence of the spouse, with increased agitation when the spouse left and calmer demeanor during visits. Staff also noted that the resident was less resistive to care when the spouse was present and more likely to hit female caregivers if approached unexpectedly. The Social Services Director, responsible for the dementia care plan, relied primarily on her own observations and staff-initiated feedback, acknowledging that more comprehensive staff input was needed to address the resident's behavioral and dementia-related needs.
Failure to Implement Physician-Ordered Physical Therapy
Penalty
Summary
A deficiency occurred when a resident with a history of bilateral heel bone fractures and multiple rib fractures, who was cognitively intact, did not receive physician-ordered physical therapy services. After a physician visit, the resident received a hard copy order from a bone specialist for continued physical therapy two times a week for eight weeks and handed it to a nurse upon returning to the facility. However, the order was not entered into the resident's health record, and no current order for physical therapy was found. Staff confirmed that the therapy order was not communicated or entered, and the resident was not scheduled for the prescribed therapy sessions.
Failure to Accurately Document and Perform Feeding Tube Bag Changes
Penalty
Summary
The facility failed to accurately document and perform feeding tube treatments for a resident with significant medical conditions, including acute respiratory failure, pneumonia, stroke, and tracheostomy status. Physician orders required the resident to receive tube feeding formula with a new bag set up daily at a specified time. However, observation revealed that the tube feeding bag in use was labeled with a date several days prior, and staff confirmed that the bag and tubing had not been changed on multiple consecutive days, despite documentation in the Treatment Administration Record (TAR) indicating otherwise. Interviews with staff and review of records confirmed that the feeding tube bag and tubing were not changed as required, and the documentation was inaccurate.
Failure to Timely Investigate and Assess Resident Falls
Penalty
Summary
The facility failed to complete timely assessments and thorough investigations following falls for two residents. For one resident with dementia and a history of falls, staff found the individual on the floor with a hip injury and a wet floor due to incontinence. The fall report lacked additional staff interviews and did not reach a conclusion regarding the incident. Staff involved did not complete the fall report or protocol promptly, and no witness statements were collected. The care plan was later revised, but it did not address the correct fall prevention measures, and staff acknowledged the investigation was incomplete. For another resident with Huntington's Disease and moderate cognitive impairment, a fall occurred but the investigation was not completed until several weeks later, and the fall care plan was not updated. Staff confirmed that the investigation was delayed until the resident was being discharged. In both cases, the facility did not follow its own policy requiring timely and thorough investigations, including collecting witness statements and updating care plans after determining the root cause.
Survey Results Not Accessible to Residents or Visitors
Penalty
Summary
The facility failed to ensure that state survey inspection results were readily accessible to residents and visitors. During a resident council interview, eight residents reported they did not know where to find the survey results within the facility. A subsequent tour of all three facility halls revealed that there were no posted survey results or signage indicating where this information could be located. The facility administrator confirmed that the state survey inspection results were not available for residents or visitors to view.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that accurate nurse staffing information was posted daily, as required. A review of the Direct Care Staff Daily Reports for the month revealed that on 10 out of 31 days, the registered nurse information was not documented. This deficiency was confirmed during an interview with the Administrator, who acknowledged that the staffing forms were incomplete for the identified days. No specific residents or their medical conditions were mentioned in the report.
Failure to Implement Diabetic Management Orders
Penalty
Summary
The facility failed to follow physician orders related to diabetic management for a resident diagnosed with diabetes and a UTI. A physician's progress note dated February 19, 2025, indicated a new order to check the resident's capillary blood glucose (CBG) every morning, at bedtime, and as needed for signs of hypoglycemia or hyperglycemia. However, a subsequent progress note on February 26, 2025, revealed that these orders were not implemented. A review of the diabetic administration record showed that the order was only implemented on February 26, 2025, seven days after the initial order. On March 4, 2025, a staff member acknowledged the delay in implementing the physician's order.
Failure to Provide Prescribed Physical Therapy
Penalty
Summary
The facility failed to provide the required rehabilitation services for a resident who was admitted with multiple fractures. The resident was prescribed physical therapy five times a week for eight weeks, starting from December 24, 2024. However, the therapy service log indicated that the resident only received seven sessions during this period, missing four sessions on specific dates. A concern was reported on December 31, 2024, regarding the missed therapy sessions. Staff 9, the physical therapist, confirmed that due to staffing issues, they were unable to provide the prescribed therapy to the resident. Staff 2, the Director of Nursing Services, acknowledged that the resident did not receive therapy as ordered.
Failure to Update Facility Assessment and Provide Tube Feeding Resources
Penalty
Summary
The facility failed to update its Facility Assessment to reflect current ownership and staffing, which led to a deficiency in the care provided to residents with tube feeding requirements. The assessment still listed the previous owners, Prestige McMinnville, instead of the current owners, PACs, and did not include the current administrator or Director of Nursing Services (DNS). Additionally, the Quality Improvement Director mentioned in the assessment was no longer employed by the facility. The assessment indicated that the facility accepted residents with feeding tubes and that nursing staff would receive training upon hire and in monthly sessions. However, there was no evidence that such training had been conducted. An inspection of the facility's supply closet revealed a lack of necessary feeding or naso-gastric (NG) tubes, and the DNS confirmed that the facility did not have these supplies on hand. Furthermore, the DNS acknowledged that the staff had not been trained to insert feeding or NG tubes, despite the facility's acceptance of residents requiring such care. The administrator admitted that the Facility Assessment had not been updated as required, which contributed to the oversight in training and equipment availability for residents with feeding tube needs.
Lack of Training and Competency in Feeding and NG Tube Management
Penalty
Summary
The facility failed to ensure that nursing staff were trained and competent in managing feeding tubes and nasogastric (NG) tubes, which are critical for the care of residents requiring nutritional supplementation. During the survey, it was found that three staff members lacked documented competencies in these areas. The Director of Nursing Services (DNS) mentioned a nurse's meeting held in May or June where NG tube training was supposedly presented, but no documentation could be provided to confirm this. Additionally, the facility's administrator confirmed that no training or competency documentation existed for feeding tubes and NG tubes, and that agency nurses received no additional training upon starting work at the facility. The Human Resources coordinator provided an orientation checklist that did not include tube feeding or NG tube training, further indicating a lack of proper training protocols for these essential skills.
Inadequate Investigation of Abuse and Neglect Allegations
Penalty
Summary
The facility failed to thoroughly and timely investigate allegations of abuse and neglect for three residents. For Resident 1, who was admitted with diagnoses including stroke and dementia, an incident occurred where a male allegedly entered the resident's room and attempted to remove the resident's brief. The investigation was incomplete, lacking details such as who conducted it, when it was completed, and whether it was reviewed by the Administrator or DNS. Additionally, interviews were not properly documented, and not all relevant staff were interviewed. The Administrator acknowledged the investigation was not thorough or timely. Resident 5, admitted with diabetes, was discharged without necessary follow-up care, including a primary care physician or home health services, despite having an indwelling urinary catheter and a Wound Vac. The facility's investigation into this unsafe discharge was inadequate, missing witness or staff interviews and lacking evidence of review by the Administrator or DNS. For Resident 13, admitted with a fracture and cirrhosis, there was a failure to investigate concerns about the resident's roommate and missed medication doses. The Facility Reported Incident was incomplete, lacking necessary observations, interviews, and a review of clinical records. The Administrator admitted to not conducting thorough interviews and submitting the report late.
Delayed Baseline Care Plans for Two Residents
Penalty
Summary
The facility failed to complete baseline care plans within the required timeframe for two residents, placing them at risk for unmet care needs. Resident 3, who was admitted with diagnoses including liver transplant and diabetes, did not have a baseline care plan completed until 32 days after admission. Similarly, Resident 1, admitted with diagnoses including dementia, stroke, and chronic obstructive pulmonary disease, had their baseline care plan completed 21 days post-admission. These delays were confirmed by Staff 2 (DNS) during an interview and record review.
Inadequate Discharge Planning for Two Residents
Penalty
Summary
The facility failed to ensure proper discharge planning for two residents, leading to potential risks for their health and well-being. Resident 5, who had dementia and multiple wounds requiring a wound vac, was discharged without a primary care provider, home health services, or necessary medical equipment. Despite being informed that the resident's previous provider no longer accepted their insurance, the facility proceeded with the discharge, leaving the resident to seek urgent care or emergency department services for wound vac maintenance. This resulted in the resident visiting the emergency department due to a malfunctioning wound vac and a lack of proper wound care. Similarly, Resident 4, who had been admitted with acute respiratory failure, was discharged without confirmed home health therapy services. Although a referral for home health was sent prior to discharge, the services were not initiated until 15 days post-discharge due to a delay in re-establishing care with the resident's provider. The Social Service Director did not confirm the start date for home health services before the resident's discharge, leading to a significant gap in necessary care and support for the resident after leaving the facility.
Failure to Administer Medications and Notify Physicians
Penalty
Summary
The facility failed to adhere to physician orders and notify the physician of omitted medications for three residents, leading to unmet medication and treatment needs. Resident 2, admitted with diagnoses including diabetes and sepsis, did not receive several medications and treatments as ordered, including amoxicillin, gabapentin, quetiapine fumarate, insulin glargine, and insulin lispro, along with capillary blood glucose checks. These omissions were verified by the Director of Nursing Services (DNS). Resident 3, with a history of liver transplant and diabetes, also experienced multiple medication administration failures. Methocarbamol, simethicone, and chlorhexidine were not administered as ordered, and several medications, including midodrine, methocarbamol, metoprolol, and apixaban, were given late. Additionally, insulin lispro was not administered due to missed capillary blood glucose checks, and wound care orders were not followed. A stool sample for c-diff testing was delayed by six days. Resident 13, diagnosed with cirrhosis of the liver and a fractured femur, missed two doses of lactulose, and the provider was not notified promptly, resulting in a delayed adjustment of the medication dosage.
Inadequate NG Tube Care and Training
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with a nasogastric (NG) feeding tube, leading to multiple instances where the resident did not receive necessary nutrition. The resident, who was admitted with chronic hepatic failure and dysphagia, had an NG tube for nutritional support. Despite physician orders for regular verification of tube placement and water flushes, the facility staff repeatedly called 911 due to clogged NG tubes on several occasions, resulting in the resident being transferred to the hospital multiple times. The facility lacked NG tube supplies and did not provide adequate training or competency checks for staff on NG tube management. Interviews with various staff members, including the Director of Nursing Services (DNS), Licensed Practical Nurses (LPNs), and the Infection Preventionist, revealed that the facility did not have the necessary supplies or training protocols in place for managing NG tubes. Staff members admitted to insufficient training and a lack of competencies for handling NG tubes, and the facility did not supply NG tubes for replacement or maintenance. The facility's administrator acknowledged these deficiencies, confirming that the nurses had not been trained on tube feedings and that the facility did not provide the necessary supplies for NG tube care.
Medication Errors in Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two residents. Resident 3, who was admitted with a liver transplant and diabetes, experienced multiple medication errors. These included missed doses of midodrine on two occasions, a missed dose of valganciclovir, and several instances of late administration of prednisone, valganciclovir, and tacrolimus. These medications are critical for preventing organ rejection and managing the resident's health post-transplant. The errors were acknowledged by the Director of Nursing Services (DNS) on November 21, 2024. Resident 13, admitted with alcoholic cirrhosis of the liver, also experienced significant medication errors. The resident's medication regimen included lactulose, essential for managing hepatic encephalopathy by removing toxins from the bloodstream. However, doses of lactulose were not administered on two occasions, which was acknowledged by the Interim DNS on November 19, 2024. The failure to administer these medications as ordered placed the resident at risk for severe health complications.
Failure to Administer Medications Timely
Penalty
Summary
The facility failed to ensure physician orders were followed for 12 of 15 sampled residents reviewed for medications. This failure placed residents at risk for reduced medication efficacy and adverse medication side effects. For instance, Resident 94, who was admitted with diagnoses including cellulitis and a pressure ulcer, did not receive her medications on time on multiple occasions. Staff members acknowledged the delays, citing reasons such as being occupied with other residents and starting their shifts late. Another instance involved Resident 144, who was admitted with heart failure. The resident did not receive their prescribed medications, Eliquis and metoprolol, on the evening of their admission and did not receive the first dose until the following morning. Staff members confirmed the delay and acknowledged the oversight. Additionally, multiple residents, including Residents 32, 28, 1, 10, 33, 4, 11, 14, 145, and 30, experienced significant delays in receiving their medications. These delays ranged from one hour to six hours late, affecting various medications such as insulin, carvedilol, and gabapentin. Staff members confirmed these delays during medication administration audits and acknowledged the issues when made aware of them.
Insufficient Staffing Leads to Delayed Care
Penalty
Summary
The facility failed to ensure sufficient staffing to meet resident care needs, as evidenced by multiple observations, interviews, and record reviews. On 4/18/24, the facility provided lists of residents requiring various levels of assistance, including eating, transfers, dressing, bathing, toileting, and incontinence care. Resident Council Notes from January and February 2024 highlighted concerns about delayed call light responses, with specific instances of call lights not being answered during shift changes and residents being left in soiled briefs. Observations on 4/17/24 revealed call light response times ranging from 23 to 26 minutes, and resident interviews indicated wait times of up to two hours, leading to episodes of incontinence and delayed medication administration. Staff interviews corroborated these findings, with multiple staff members reporting being unable to complete their duties due to short staffing. A CMA stated she was the only one passing medications for the entire facility, often finishing morning medications just before noon. CNAs and LPNs reported difficulties in taking breaks, completing assigned duties, and managing high-acuity residents. One LPN was observed to have ten residents with late medications due to being pulled in multiple directions. Another LPN confirmed that medications were often given late at night due to the high volume of tasks, including new admissions and assessments. The deficiency was further supported by specific resident and staff testimonies. Residents reported lengthy call light response times, leading to incontinence and delayed care. Staff members described the challenges of managing high-demand residents and completing their tasks on time. The overall findings indicate that the facility's staffing levels were insufficient to meet the care needs of the residents, resulting in delayed and unmet care needs, including incontinence care and timely medication administration.
Failure to Ensure Residents Were Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure residents were free from unnecessary medications for two residents. Resident 6, who was admitted with end-stage renal disease, had a physician order to receive midodrine TID PRN if the systolic blood pressure was less than 90. However, from mid-March to mid-April, there were 83 instances where midodrine was administered despite the systolic blood pressure being greater than 90. Staff 2 acknowledged this discrepancy. Similarly, Resident 4, admitted with diabetes, had a physician order to receive insulin lispro 13 units before meals, to be held if the CBG was less than 120. Despite this, there were seven instances from mid-March to mid-April where insulin was administered even though the CBG was below 120. Staff 2 also acknowledged this error.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling of biologicals, proper storage temperatures were logged and maintained, and medication carts were properly secured. Specifically, two open insulin pens were found in the 300-hall treatment cart and one open insulin pen in the 200-hall treatment cart, all without open dates. Staff acknowledged the insulin pens were open and not labeled with open dates. Additionally, the controlled medication refrigerator contained a thermometer and medications but lacked a temperature log. The temperature logs for March and April 2024 indicated multiple instances where temperatures were not logged twice daily, and on several occasions, the temperatures were outside the required range of 36 F to 46 F. Staff were unsure who was responsible for recording the temperatures, and the Director of Nursing Services acknowledged the discrepancies in temperature logging and out-of-range temperatures. Furthermore, on two separate occasions, a treatment cart containing antibiotics and blood pressure medications was observed to be unlocked and unattended in the long-term care nursing unit. Staff confirmed the cart was unattended and unlocked and subsequently locked it. These lapses in medication management placed residents at risk for reduced efficacy of medication and unauthorized access to medications.
Inaccurate MDS Coding for Oxygen Therapy
Penalty
Summary
The facility failed to accurately code MDS assessments for a resident who required oxygen therapy. Resident 295, admitted with diagnoses including asthma and acute respiratory failure with hypoxia, had admission orders indicating the need for continuous oxygen therapy. Despite this, the resident's 4/5/24 Admission MDS inaccurately indicated that the resident did not require oxygen. This discrepancy was confirmed through interviews and record reviews, including observations of the resident using oxygen and statements from the resident and staff. The Resident Care Manager acknowledged the coding error on 4/18/24.
Failure to Provide Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to ensure a written summary of a baseline care plan was reviewed and provided to residents within 48 hours of admission. This deficiency was identified for one resident who was admitted in December 2023 with diagnoses including diabetes and kidney failure. The resident's care plan dated December 26, 2023, did not indicate that the baseline care plan was received or reviewed. Additionally, the resident's Medication Administration Record (MAR) for December 2023 revealed no documentation that the baseline care plan was provided or reviewed. This was confirmed by a Resident Care Manager during an interview on April 19, 2024.
Failure to Update Care Plan for Resident
Penalty
Summary
The facility failed to ensure care plans were revised to accurately reflect the needs of residents. Resident 246, who was admitted in June 2023 with diagnoses including dementia and hypertension, had a care plan dated January 29, 2024, indicating that staff were to wake the resident at 2:00 AM every morning to void. However, on April 17, 2024, three CNAs stated they were not aware of this intervention and noted that the resident was often up and down at night, suggesting the intervention did not fit the resident's current needs. On April 19, 2024, the Director of Nursing Services confirmed that the intervention was not current and the care plan needed updating.
Failure to Ensure Proper Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure pressure ulcers were assessed, treated, and care planned appropriately for a resident admitted with multiple skin impairments, including pressure ulcers on both heels and a Stage 2 pressure ulcer on the right elbow. The initial care plan did not identify the resident's pressure ulcers or include specific interventions for them. Despite receiving orders for wound care, including daily dressing changes, there was no indication that these treatments were implemented from the time of admission until several days later. The resident reported that dressings were not changed for a couple of nights, and staff were unsure of the resident's skin issues or the required interventions. Upon assessment by the wound care nurse practitioner, it was found that the dressings on the resident's heel wounds were dated several days prior, and there was no comprehensive assessment, measurements, or treatments implemented until a week after admission. The wound care nurse practitioner identified multiple unstageable pressure ulcers and a Stage 3 pressure ulcer on the left heel. The Director of Nursing Services acknowledged the lack of timely and appropriate wound care for the resident, confirming the deficiency in pressure ulcer management and care planning.
Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure accurate medical records for one resident, leading to a risk of inaccurate treatment. Resident 246, who had dementia and hypertension, was documented as receiving pantoprazole at 5:20 AM. However, the resident was found deceased at 7:15 AM, with police and coroner findings indicating the death occurred much earlier, around midnight. A former employee admitted to administering the medication the night before and not checking on the resident for the rest of the shift. The administration time was confirmed to be documented incorrectly by both the former employee and the facility administrator.
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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