Fairlawn Health And Rehab Of Cascadia
Inspection history, citations, penalties and survey trends for this long-term care facility in Gresham, Oregon.
- Location
- 3457 Ne Division Street, Gresham, Oregon 97030
- CMS Provider Number
- 385133
- Inspections on file
- 19
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Fairlawn Health And Rehab Of Cascadia during CMS and state inspections, most recent first.
The facility failed to properly label and store food, risking foodborne illness. Observations included unlabeled milk and juice, uncovered cereal, and dirty kitchen equipment. The Dietary Manager and Administrator acknowledged these issues, highlighting the need for improved cleanliness and food storage practices.
A resident with dementia and a periprosthetic fracture was discharged from an LTC facility without proper planning or education for the resident and their family. The resident required assistance with catheter care and medication management, but the family was not notified in advance or trained on these needs. Home health services were not arranged, and the discharge plan lacked necessary support, leading to a deficient discharge process.
A facility failed to maintain a homelike environment by not ensuring the cleanliness of a recliner in a resident's room. The chair was stained with an unknown residue and lacked a cleanable surface. Staff, including a CNA, Infection Preventionist, and Housekeeping, acknowledged the chair's filthy condition, and the Administrator confirmed it had a bad odor.
A resident with severe cognitive impairment and a history of falls was not provided with the prescribed fall prevention interventions. The resident's care plan required a low bed position with a fall mat, but observations showed the bed was elevated for transfers, contrary to the care plan. Staff confirmed the resident was part of a fall prevention program, yet the interventions were not consistently followed.
A resident with urine retention and a Foley catheter returned to the facility with orders for an immediate catheter change, which was not performed on the specified days. Staff acknowledged the oversight, with one intending to contact the physician but failing to do so, and another citing time constraints. The DNS confirmed the catheter was not changed as ordered.
A facility failed to complete a discharge summary for a resident with malnutrition who was discharged home. The care plan included referrals for home health and therapy services, but the Social Services Director confirmed the absence of a discharge summary in the resident's record. A home health staff member reported unreturned calls for necessary physician orders and instructions. The previous Social Services Director was unavailable for interview, and the facility administrator provided no further information.
The facility failed to follow physician orders for bowel care for two residents, leading to a deficiency in care. One resident with atrial fibrillation and constipation did not receive timely bowel medications, resulting in an 11-day period without a bowel movement. Another resident with a stroke diagnosis experienced delays in receiving prescribed bowel medications, with a six-day gap before a suppository was administered. Both cases highlight significant lapses in adhering to bowel care protocols.
The facility failed to follow physician orders for medication administration for a resident with a UTI, leading to multiple instances of delayed medication administration outside the prescribed two-hour window. The administrator confirmed these delays occurred on several dates in October 2023.
Deficiencies in Food Storage and Kitchen Cleanliness
Penalty
Summary
The facility failed to ensure proper labeling and storage of food and beverages, which placed residents at risk for foodborne illness. During an inspection, surveyors observed three trays of unlabeled and undated cups of milk and juice, an uncovered and unlabeled large plastic bin of dry oat cereal, an opened and undated five-pound plastic tub of peanut butter with smeared contents, an opened and undated bag of salad greens, and a plastic bin containing four eggs, one with a broken shell. The Dietary Manager acknowledged these issues, stating that items should be wrapped, labeled, and dated to prevent spoilage and cross-contamination. Additionally, the facility's equipment and kitchen cleanliness were found to be inadequate. The gaskets on the refrigerator doors were grimy and not sealing properly, and multiple in-floor drains were observed to be dirty with black grime and food debris. The Dietary Manager confirmed these observations, noting that the gaskets were old and did not close well, and that the drains needed cleaning. The facility administrator acknowledged these findings and stated that the kitchen staff was expected to maintain cleanliness and proper food storage practices.
Inadequate Discharge Planning for Resident with Complex Needs
Penalty
Summary
The facility failed to ensure a safe discharge for a resident who was admitted with a periprosthetic fracture and experienced dementia. The resident required assistance with various activities, including catheter care and medication management, and had ongoing health issues such as dizziness and unstable blood pressure. Despite these needs, the discharge plan was inadequately executed, with no evidence of proper education or preparation for the resident or their family. On the day of discharge, the resident was sent home with a foley catheter, but there was no documentation indicating that the resident or their family received instructions on catheter care or medication administration. The family was not notified of the discharge in a timely manner, and there was no confirmation that a family member would be present to assist the resident upon arrival home. Additionally, home health services were not arranged, leaving the resident without necessary support. Interviews with staff and family members revealed a lack of communication and preparation for the discharge. The resident's family was informed of the discharge only two hours before the resident's arrival home, and they were not trained on the care required for the resident's catheter or medications. Staff acknowledged the deficiencies, noting the need for better training and documentation to ensure safe discharges in the future.
Failure to Maintain a Homelike Environment Due to Unclean Recliner
Penalty
Summary
The facility failed to ensure a homelike environment for residents in one of the rooms reviewed. During an observation, a cloth recliner chair in the room was found to be stained with an unknown brown dried residue on the seat and armrests. Staff interviews revealed that the chair was considered filthy and lacked a cleanable surface. The CNA and Infection Preventionist both acknowledged the chair's dirty condition. The Housekeeping staff admitted to having a monthly cleaning schedule for recliners but did not clean the chair in question because it was made of cloth. The Administrator confirmed the chair's dirty state and noted it had a bad odor.
Failure to Follow Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that safety interventions for fall prevention were followed for a resident with severe cognitive impairment and a history of falls. The resident, who was admitted with diagnoses including age-related osteoporosis and severe vascular dementia, was assessed to be at risk for falls due to incontinence, impaired cognition, and impaired functional mobility. The care plan for the resident included having a low bed positioned against the wall and in the lowest position with a fall mat at the bedside to minimize injury risk from falls. However, observations on multiple occasions revealed that the resident's bed was elevated to a height suitable for wheelchair transfers and not in the low position as required by the care plan. There were no caregivers present in the room during these observations. Staff members, including a CNA and an RN, confirmed that the resident was part of the facility's Falling Star program, which required staff to ensure the bed was in the lowest position. Despite this, the bed was consistently found at a higher position, indicating a failure to adhere to the prescribed fall prevention interventions.
Failure to Follow Catheter Care Orders
Penalty
Summary
The facility failed to follow catheter care orders for a resident who was admitted with a diagnosis of urine retention and required the use of a Foley catheter. The resident had normal cognitive function and returned to the facility after a surgical procedure with specific instructions for the Foley catheter to be changed immediately. However, the catheter was not changed on the day of the resident's return or the following day, as confirmed by the resident and staff interviews. Staff members involved in the resident's care acknowledged the failure to change the catheter as ordered. One staff member intended to contact the physician for clarification but did not follow through, while another staff member cited time constraints as the reason for not completing the catheter change. The Director of Nursing Services confirmed that the catheter change was not performed as ordered, indicating a lapse in following medical orders and meeting the resident's care needs.
Failure to Complete Discharge Summary for Resident
Penalty
Summary
The facility failed to complete a discharge summary for a resident who was admitted with diagnoses including malnutrition. The resident's care plan, revised on 9/29/23, indicated a planned discharge home with referrals for home health, physical and occupational therapy, and other medically related services. However, the Social Services Director confirmed that the resident did not have a discharge summary in their clinical record for 2023. A home health staff member reported attending a care conference before the resident's discharge, where the facility agreed to make necessary referrals and send paperwork to the home health agency. Despite multiple phone calls to the previous Social Services Director requesting physician orders and instructions, the home health staff did not receive a response. The resident's clinical record lacked a discharge summary, and progress notes indicated the resident was discharged home on 9/17/23. The previous Social Services Director was no longer employed at the facility and could not be interviewed. The facility administrator was informed of these findings but provided no additional information.
Failure to Follow Bowel Care Protocols for Two Residents
Penalty
Summary
The facility failed to adhere to physician orders for bowel care for two residents, leading to a deficiency in care. Resident 3, admitted with diagnoses including atrial fibrillation and constipation, had specific physician orders for bowel medications to be administered daily. Despite these orders, the resident's bowel logs for October 2023 showed no bowel movement from October 22 to October 31. The medication administration record (MAR) indicated that the bowel protocol was not followed correctly, with delays in administering prescribed medications such as Polyethylene Glycol Powder, Bisacodyl suppository, and Fleet Mineral Oil enema. The resident went without a bowel movement for 11 days, highlighting a significant lapse in following the bowel protocol. Similarly, Resident 4, admitted with a diagnosis of stroke, also experienced a failure in the administration of bowel medications as per physician orders. The resident's MAR revealed that Polyethylene Glycol Powder was not administered from October 20 to October 23, and a Bisacodyl suppository was only given on October 24, six days after the last recorded bowel movement. This delay in following the bowel protocol resulted in a deficiency in care for Resident 4. Both residents were no longer in the facility at the time of the investigation, and the facility's Director of Nursing Services confirmed the failure to follow the bowel protocol.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to follow physician orders for medication administration for one resident, leading to delays in medication administration. The resident, admitted in September 2023 with a diagnosis of a urinary tract infection (UTI), had specific physician orders for medications to be administered at 7:15 AM. These medications included Polyethylene Glycol Powder, Potassium Chloride ER, Torsemide, Cipro, and Nitrofurantoin Macrocrystal. However, a review of the Medication Admin Audit Report for October 2023 revealed multiple instances where the medications were administered outside the prescribed two-hour window (6:15 AM to 8:15 AM). The administrator confirmed that the resident received medications outside of this timeframe on several dates, including October 5, 7, 13, 20, 21, 27, and 28.
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.
Trusted by long-term care providers and associations.
