Fernhill Rehabilitation And Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Portland, Oregon.
- Location
- 5737 Ne 37th Avenue, Portland, Oregon 97211
- CMS Provider Number
- 385237
- Inspections on file
- 20
- Latest survey
- August 8, 2025
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at Fernhill Rehabilitation And Care during CMS and state inspections, most recent first.
The facility did not provide written or verbal responses to concerns raised by resident council members during two meetings, despite policy requiring tracking and resolution of such issues. Concerns included care, staff performance, cleanliness, and food services. Staff and residents confirmed that concerns were documented and shared, but no feedback was given to the council.
A resident with depression and anxiety, who was cognitively intact, reported missing personal property and submitted multiple grievances. The facility did not document resolutions, obtain signatures, or notify the resident of investigation outcomes, as required by policy. Both the Social Services Director and Administrator confirmed the grievance process was not properly followed.
Surveyors found that kitchen food prep areas were not kept clean or sanitary, with hundreds of small bugs present on surfaces and in traps, missing and uncleanable caulking, and a persistent rancid odor under the food prep sink. Staff confirmed ongoing issues with bugs swarming, migrating to food prep areas, and biting staff, as well as a longstanding foul smell that had not been resolved.
A resident who was cognitively intact and used a power wheelchair was discharged from the facility, but staff failed to return the resident's wheelchair. Instead, the wheelchair was stored for several months and then disposed of without any attempt to deliver it back to the resident.
Surveyors found that the facility did not provide a homelike environment in two of three hallways reviewed. A resident's personal fan was observed with a thick layer of dust and grime, and the resident reported waiting for staff to clean it. Multiple rooms had walls with scrapes, holes, and uncleanable surfaces, as well as dust build-up, sticky furniture, and other cleanliness issues. Residents and staff confirmed the need for cleaning and repairs.
A resident with a history of stroke and significant dental issues, including missing upper teeth and broken tooth fragments, was observed to have difficulty chewing certain foods. Despite these findings, the resident's MDS assessments inaccurately documented no difficulty chewing and no dental problems. The DNS confirmed the assessments did not accurately reflect the resident's dental condition.
A resident with chronic kidney disease and dementia, identified as being at increased risk for falls, did not have their call light consistently within reach as required by their care plan. Multiple observations found the call light out of reach, and staff confirmed both the resident's fall history and the expectation to keep the call light accessible, but acknowledged this was not always done.
A resident with anxiety and depression, who was cognitively intact and had specific leisure interests, was not provided with meaningful or preferred activities. Despite documented preferences for outdoor time and music, the resident reported frequent boredom and had minimal participation in activities, with limited documentation of engagement. The care plan included activities not aligned with the resident's stated interests, and staff acknowledged challenges in meeting individual preferences and documenting participation.
A resident with a history of stroke and diabetes, who reported worsening vision, was referred by the facility optometrist to a retina specialist, but no appointment was scheduled and the resident was not seen by a specialist. Despite repeated requests to staff over several months, the resident did not receive the necessary vision care, and staff confirmed that no appointment had been arranged.
A resident with a history of stroke and diabetes, who was missing most of their teeth and required dental care, repeatedly requested assistance from the Social Service Director to schedule an outside dental appointment for tooth fragment removal and denture fitting. Despite these requests and staff awareness, no dental appointment was scheduled, and the resident's medical record showed no evidence of dental services being provided.
A resident with depression and scoliosis was physically abused by another resident with a history of stroke, who entered the resident's room, pushed them onto the bed, and held the door shut from the outside. The incident was confirmed by the facility administrator following the resident's report to staff and law enforcement.
A resident was physically pushed onto a bed by another resident, who then held the door shut to prevent exit. Although staff were aware of the incident, the administrator was not informed until several hours later, resulting in a late submission of the required abuse report to the state agency.
The facility did not ensure that daily nurse staffing postings were accurate and complete, with multiple days showing missing or incomplete information such as nurse and CNA hours, census data, dates, and required signatures. These deficiencies were confirmed by the staffing coordinator during a review.
A resident with a mental health diagnosis and history of exit-seeking behavior eloped from the facility after being left unsupervised at the front door when a CNA briefly left to notify a nurse. The resident, who was cognitively impaired and refused medications, was later found by police several blocks away. Staff interviews confirmed that 1:1 supervision was required but not maintained at the time of the incident.
A resident with diabetes and end stage renal disease, identified as a fall risk, was left unattended for an extended period after using the call light to request transfer assistance. Due to lack of staff response, the resident attempted to self-transfer from a bedside commode, resulting in a fall and a fractured femur. Staff interviews confirmed that the assigned CNA was absent from the unit, and other staff were either unaware or occupied with other duties, leading to inadequate supervision and delayed assistance.
A resident with a history of aggressive behavior and alcohol dependence physically assaulted another resident following a verbal altercation, despite existing behavioral care plans instructing staff to intervene. Staff and clinical documentation confirmed the aggressor had been drinking and that the altercation escalated to physical abuse, with no injuries reported.
A resident with atrial fibrillation did not receive prescribed apixaban for several days after returning from a hospital stay, due to the admitting nurse failing to input the medication order. The medication was marked as on hold in the MAR without explanation, and staff confirmed there was no physician order to hold the drug. The error was recognized as a significant medication error by facility staff.
A resident with severe cognitive impairment and a high risk of elopement was not provided with the necessary interventions outlined in their care plan. Despite being observed near the facility's entrance, staff failed to engage or redirect the resident as required, until the Activities Director intervened. The facility administrator was informed of these findings.
A resident with severe cognitive impairment and a history of elopement risk managed to leave the facility undetected and was found at a bus stop several blocks away. Staff interviews revealed inconsistencies in supervision and redirection strategies, and the facility's investigation lacked thoroughness, failing to address the root cause of the security lapse. No management staff were present post-incident, and key staff involved in the search were not interviewed.
Failure to Respond to Resident Council Concerns
Penalty
Summary
The facility failed to provide written or verbal responses to concerns raised by resident council members during two of four reviewed meetings. According to facility policy, a Resident Council Response Form should be used to track issues and their resolution, with the relevant department responsible for addressing concerns. However, review of meeting records from two specific dates showed that concerns such as lack of toenail care, staff performance, facility cleanliness, care conferences, snack accessibility, outdoor access, food temperature, fresh fruit availability, community outings, lost clothing, unanswered call lights, and staff responses to concerns were documented but not addressed. No evidence was found of any responses being provided to the resident council regarding these issues. Interviews with staff and residents confirmed that concerns were recorded and shared with appropriate departments, but no follow-up or feedback was given to the resident council. The Activities Director stated she forwarded concerns to the relevant departments but did not receive any responses. Residents reported submitting concerns in writing but not receiving any feedback. Department heads, including the DNS, Dietary Manager, and Housekeeping Manager, indicated they either did not receive the concerns or were not instructed to provide written responses. The Administrator confirmed that while concerns were discussed among staff, no direct communication was provided to the resident council for the meetings in question.
Failure to Communicate Grievance Resolutions to Resident
Penalty
Summary
The facility failed to provide a written grievance resolution or communicate the outcome of a grievance to a resident or the resident's representative regarding missing personal property. According to the facility's policy, grievances are to be documented and resolved within five working days, with outcomes communicated to the resident. Record review showed that a resident with diagnoses of depression and anxiety, who was cognitively intact, reported multiple missing items and stated that staff were aware of the concerns but did not inform the resident about any investigation or resolution. A review of the grievance binder revealed four grievances submitted by the resident, none of which included documented resolutions, signatures, or evidence that the resident was notified of the investigation results. The Social Services Director confirmed responsibility for grievance follow-up but acknowledged the forms were incomplete and could not provide evidence of resident notification. The Administrator also confirmed that the grievance process was not followed, and forms were not completed as required.
Failure to Maintain Sanitary Kitchen Conditions Due to Pest Infestation and Odor
Penalty
Summary
Surveyors observed that the facility failed to maintain the kitchen food preparation areas in a clean and sanitary condition. During multiple kitchen inspections, hundreds of small bugs with wings were seen on the windowsill above the food prep sink, in the food prep sink, and on the steel counter where food was prepared. Additionally, a bug trap on the windowsill contained hundreds of bugs, and bugs were observed flying near the clean food prep area and inside the sanitary cleaning bucket used for wiping down food prep surfaces. The caulking along the windowsill above the food prep sink was missing and uncleanable, and a rancid odor was noted coming from under the food prep sink. Staff interviews confirmed that the issue with the bugs had been ongoing, with the bugs swarming the window and windowsill, migrating to the food prep sink and counters, and even biting kitchen staff. Staff also confirmed that the rancid smell under the food prep sink had persisted for some time, despite attempts to identify and treat the source, and described the odor as resembling that of a dead animal. These conditions were directly observed and confirmed by staff, indicating a failure to control pests and maintain sanitary food preparation areas as required by professional standards and the FDA Food Code.
Failure to Return Resident's Power Wheelchair After Discharge
Penalty
Summary
A resident with congestive heart failure, who was cognitively intact as indicated by a BIMS score of 15, was admitted to the facility in March 2024 and utilized a personal power wheelchair. Upon transfer to a hospital and subsequent discharge to another facility in May 2024, no attempt was made by the facility to return the resident's power wheelchair. Interviews with the Social Service Director and Maintenance Director revealed that the wheelchair was stored in a shed for six months after the resident's discharge and was ultimately disposed of during a storage area cleanup in October 2024. The Administrator confirmed that the wheelchair, found to be non-operational, was not returned to the resident.
Failure to Maintain a Homelike and Clean Environment in Resident Rooms
Penalty
Summary
Surveyors identified that the facility failed to maintain a homelike environment in two of three hallways reviewed. In one instance, a resident with congestive heart failure and a BIMS score indicating cognitive intactness had a personal fan on the bedside table that was coated with a thick, visible accumulation of dust, lint, and grime on the blades and protective grill. The resident reported wanting the fan cleaned and had been waiting for staff to do so. The Housekeeping Supervisor confirmed that housekeepers were responsible for cleaning personal fans, and the Administrator acknowledged the fan needed cleaning and expected all personal fans to be clean. Additional observations between multiple dates revealed several resident rooms with environmental deficiencies, including walls with numerous scrapes, areas requiring painting, residual masking tape, missing and uncleanable wood on closet drawers, holes in walls, patched areas needing paint, and deep scrapes. Other issues included multiple screws and nails in walls, splashes and streaks of unknown substances, dust build-up on ceiling vents, sticky bedside tables, and malfunctioning table wheels. Residents in these rooms stated their rooms required cleaning and repairs and were not homelike. The Maintenance Director and Administrator both confirmed that the identified rooms required repairs, painting, and updating to meet homelike standards.
Inaccurate MDS Assessment of Dental Status
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments were completed for a resident with a history of stroke who was admitted in April 2020. Observations on two separate occasions revealed the resident had no upper teeth, missing lower molars, and experienced difficulty chewing certain food textures such as cucumbers and large pieces of lettuce. The resident reported missing upper teeth with three broken tooth fragments and missing teeth on both sides of the lower mouth, as well as difficulty chewing hard food items. However, the resident's quarterly and annual MDS assessments indicated no cognitive impairment, no difficulty chewing food, and no natural teeth or tooth fragments, with no obvious or likely broken natural teeth. The Director of Nursing Services confirmed that the MDS assessments were inaccurate and did not reflect the resident's actual dental status.
Failure to Ensure Call Light Accessibility for Resident at Risk for Falls
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for a resident with chronic kidney disease and dementia who was at increased risk for falls. Despite the care plan specifying that the resident's call light should be kept within reach and that the resident should be encouraged to use it for assistance, multiple observations on different occasions showed the call light was out of reach. Staff interviews confirmed that the resident had experienced recent falls and was capable of using the call light, and staff were expected to ensure the call light was accessible during every room entry. However, staff acknowledged that the call light was not always within the resident's reach, as required by the care plan.
Failure to Provide Individualized Activities for Resident
Penalty
Summary
A resident with diagnoses of anxiety and major depression, assessed as cognitively intact, was admitted to the facility and identified specific leisure interests as very important, including going outside for fresh air and engaging in favorite activities. The resident's activity assessments indicated independence in leisure pursuits and enjoyment of music, outdoor activities, television, socializing, and helping others. Despite these documented preferences, observations over several days revealed the resident was not engaged in meaningful or preferred activities, except for attending one Bingo group. The resident reported frequent boredom and a lack of interest in the group calendar activities, with limited access to music in their room. Review of activity participation records showed minimal involvement in both group and individual activities. The care plan included religious activities, despite the resident indicating religion was not important, and there was a lack of documentation regarding activity participation. The Activity Director acknowledged the difficulty in planning activities to meet all residents' interests and confirmed the lack of documentation for this resident. The Administrator also recognized the need for improvement in providing personalized activities and ensuring documentation of resident participation.
Failure to Arrange Vision Services for Resident with Declining Vision
Penalty
Summary
The facility failed to obtain necessary vision services for a resident with a history of stroke and diabetes, who was experiencing a continual decline in vision. According to the facility's policy, staff are responsible for assisting residents in locating resources, scheduling appointments, and arranging transportation for vision care. Documentation showed that the facility optometrist referred the resident to a retina specialist, but there was no evidence in the electronic health record that an appointment was scheduled or that the resident was seen by the specialist. The resident's care plan also indicated that staff would arrange a consultation with an eye care practitioner as required, but this was not carried out. The resident reported repeatedly asking the Social Service Director over a four-month period to schedule an appointment with an eye doctor due to worsening vision, but no appointment was made. The resident was observed wearing non-prescription reading glasses and stated they did not have prescription glasses. Both the Social Service Director and the Director of Nursing confirmed that no appointment had been scheduled for the resident to see an eye doctor, despite being aware of the resident's requests and ongoing vision concerns.
Failure to Obtain Dental Services for Resident
Penalty
Summary
The facility failed to obtain necessary dental services for a resident who had been admitted with a history of stroke and diabetes. The resident's care plan indicated significant dental needs, including missing upper teeth and most lower teeth, with interventions specifying coordination of dental care and transportation. Despite these documented needs, there was no evidence in the resident's medical record that a dental appointment had been scheduled or completed. Observations confirmed the resident was missing upper teeth and had chipped and worn lower teeth. The resident reported repeatedly requesting assistance from the Social Service Director over a four-month period to schedule an appointment with an outside dental provider for removal of tooth fragments and remaining lower teeth, in order to be fitted for dentures. Both the Social Service Director and the LPN-Care Manager acknowledged awareness of the resident's requests but confirmed that no appointment had been scheduled. The Director of Nursing Services also confirmed that the dental appointment had not yet been arranged and stated that it should have been scheduled more promptly.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with a history of depression and scoliosis was physically abused by another resident who had a history of stroke. According to the facility's investigation, the incident took place when the resident awoke early in the morning to find the other resident in their room. Upon attempting to stand, the resident was pushed back onto the bed by the other resident, who then held the door shut from the outside. The affected resident subsequently called the police and informed staff of the incident. The facility administrator confirmed that physical abuse had occurred during this event.
Failure to Timely Report Alleged Physical Abuse Incident
Penalty
Summary
The facility failed to report an allegation of physical abuse within the mandated timeframe for one resident. According to the facility's policy, staff are required to report allegations of abuse promptly. On the date in question, a resident entered another resident's room, pushed the resident onto the bed, and then held the door shut from the outside, preventing the resident from leaving. Staff were aware of the incident at 4:00 AM, but the administrator was not informed until approximately 9:30 AM during a morning meeting. The Facility Reported Incident (FRI) was subsequently submitted late to the state agency, as confirmed by the administrator. This delay in reporting did not comply with the facility's abuse prevention policy.
Inaccurate Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure the accuracy and completeness of the Direct Care Staff Daily Report (DCSDR) postings for 15 out of 45 days reviewed. Specific issues identified included missing or incomplete licensed nurse staff hours, absence of CNA hours, missing census data, incorrect dates, and missing signatures on the DCSDRs. These deficiencies were confirmed during a review of the reports by the Human Resources/Staffing Coordinator, who verified the inaccuracies and incomplete information on the specified dates. This failure resulted in the posting of inaccurate staffing information, as evidenced by the review of records and staff interviews.
Resident Elopement Due to Lapse in 1:1 Supervision
Penalty
Summary
A resident with a long history of mental health issues and houselessness was admitted to the facility and assessed as being at risk for elopement. The resident's care plan included interventions such as regular monitoring, redirection, offering food and fluids, providing activities during wandering or exit-seeking episodes, and 1:1 supervision until exit-seeking behavior resolved. The resident was noted to be cognitively impaired, with poor decision-making skills, and was able to ambulate independently without an assistive device. The resident also refused medications, resulting in hallucinations and an inability to ask for assistance. On the night of the incident, the resident was observed by the front door, with a CNA assigned to monitor them. The CNA was not positioned closely due to the resident's preference for personal space. At some point, the CNA left the resident unattended for a brief period to notify the nurse that the resident was attempting to leave. During this time, the resident exited the facility without staff knowledge. Staff searched the facility and surrounding neighborhood but were unable to locate the resident, and the police were notified. The resident was later found by police several blocks away, sitting on a private residence's porch. Facility staff attempted to persuade the resident to return, but the resident refused and expressed a desire not to return. Interviews with staff confirmed that 1:1 supervision was expected when the resident exhibited exit-seeking behavior, and that the resident was left unsupervised at the door, which allowed the elopement to occur.
Failure to Provide Timely Transfer Assistance Results in Resident Fall and Fracture
Penalty
Summary
A resident with diabetes and end stage renal disease, identified as a fall risk due to medical conditions, lack of safety awareness, and poor impulse control, was not timely assisted with a transfer. The resident's care plan included interventions such as keeping the call light within reach and anticipating needs. On the evening of the incident, the resident used the call light and requested assistance from the night nurse, who was occupied with wound care. After waiting for approximately 45 minutes without staff response, the resident attempted to self-transfer from the bedside commode to the bed, resulting in a fall. Staff interviews revealed that the assigned CNA did not respond to the call light because he had left the facility to search for an eloped resident, and was unaware of the resident's need for assistance. Other staff members were either not aware of the situation or were engaged in other tasks. The resident was found on the floor after the fall, subsequently hospitalized, and diagnosed with a fractured femur. The facility's failure to provide timely assistance and adequate supervision directly contributed to the resident's accident and injury.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when one resident, with a known history of aggressive behaviors and alcohol dependence, physically assaulted another resident. The aggressor had a behavioral care plan in place instructing staff to remove other residents or the aggressor from the area if aggressive or verbally inappropriate behaviors occurred. On the day of the incident, the aggressor had been drinking and engaged in a verbal altercation with another resident near the smoking area, which escalated to the aggressor punching the other resident in the face. Staff and clinical notes confirmed that the aggressor had been drinking and that the altercation resulted in a physical assault, though no injuries were noted. The resident who was assaulted had a behavioral care plan addressing high anxiety due to a history of homelessness and medical conditions, with staff directed to provide mental health support. Despite these care plans, staff did not prevent the altercation, and the resident was struck in the face after requesting the aggressor to pick up cigarette butts. Multiple staff interviews confirmed the sequence of events, the aggressor's history of aggressive behavior, and the failure to prevent the physical abuse.
Failure to Administer Anticoagulant Following Hospital Readmission
Penalty
Summary
A resident with a diagnosis of atrial fibrillation was admitted to the facility with physician orders to receive 5 mg of apixaban twice daily. Following a hospitalization for pneumonia, the resident was readmitted to the facility with discharge orders to continue apixaban. However, the medication was not administered from the date of readmission through several days afterward, as documented in the Medication Administration Record (MAR), which showed the medication was on hold without any nursing notes explaining the reason. The admitting nurse did not input the apixaban order upon the resident's return, and there was no physician order to hold the medication. The resident reported to a complainant that they had not received their blood thinner since returning from the hospital and expressed concern about being taken off the medication. Facility staff confirmed that the apixaban was not administered until several days after readmission, and the medication could have been accessed from the emergency medication kit if not available. The physician verified that the medication was not supposed to be held, and the error was acknowledged by facility staff as a serious medication error.
Failure to Implement Elopement Risk Care Plan
Penalty
Summary
The facility failed to implement the care plan for a resident identified as a high elopement risk. The resident, who was admitted in May 2024 with diagnoses of schizophrenia and dementia, had a BIMS score of 0, indicating severe cognitive impairment. An elopement risk evaluation conducted in August 2024 confirmed the resident's high risk of elopement, as they frequently stood by the entrance door expressing a desire to leave. The care plan, dated October 2024, included interventions such as distracting the resident with diversions, activities, food, conversation, television, or a book. However, during the survey, staff members were observed failing to implement these interventions, as the resident was seen seated by the front door without any staff attempting to distract or provide a diversion. Multiple staff members, including CNAs and a Physical Therapist, were present in the area but did not engage with the resident as per the care plan. The resident was observed writing in a notebook and watching staff enter and exit the facility, but no attempts were made to redirect or engage the resident until the Activities Director offered a drink, which the resident accepted. The facility administrator was informed of these findings, but no additional information was provided to address the lack of implementation of the care plan interventions.
Inadequate Supervision and Investigation of Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision and thoroughly evaluate an elopement incident involving a resident with severe cognitive impairment. The resident, diagnosed with schizophrenia and dementia, was identified as a high elopement risk and had a history of attempting to leave the facility. Despite this, the resident managed to elope from the facility and was found at a bus stop several blocks away, indicating a lapse in supervision and security measures. Interviews with staff revealed inconsistencies in the understanding and implementation of interventions to prevent the resident from eloping. Some staff members were aware of the resident's exit-seeking behavior but were unable to effectively redirect the resident. The facility's investigation into the incident was inadequate, lacking detailed documentation, including who conducted the investigation, when it was initiated, and whether key staff members involved in the search were interviewed. The facility's investigation report did not address the root cause of the security failure that allowed the resident to leave undetected. Additionally, no management staff were present at the facility following the elopement, and the investigation did not include interviews with the CNA staff who found the resident. This lack of thorough investigation and analysis of the incident placed residents at risk for future unsafe elopements.
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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