Forest Grove Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Forest Grove, Oregon.
- Location
- 3900 Pacific Avenue, Forest Grove, Oregon 97116
- CMS Provider Number
- 385155
- Inspections on file
- 21
- Latest survey
- July 25, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Forest Grove Post Acute during CMS and state inspections, most recent first.
A resident with dementia and depression received PRN psychotropic medications without physician evaluation or documented rationale for use beyond 14 days. Staff were unaware of the 14-day limitation, resulting in the continuation of these medications past the required timeframe without proper review.
Two residents were not properly assessed or supervised for smoking safety as required by facility policy. One resident with COPD was listed as an independent smoker without a documented assessment and was observed disposing of a cigarette improperly. Another resident with vascular dementia, care planned for supervised smoking, was found with cigarettes in their personal belongings and was observed smoking without staff supervision, contrary to policy. Staff confirmed these lapses in assessment and supervision.
The facility failed to follow physician's orders for oxygen administration for five residents, leading to potential respiratory complications. Residents with conditions such as chronic respiratory failure, COPD, and heart failure were observed receiving incorrect oxygen levels. Staff acknowledged the discrepancies, indicating a systemic issue in adhering to prescribed respiratory care protocols.
A resident with a history of hypertension and diabetes experienced a worsening pressure ulcer due to the facility's failure to implement appropriate wound care treatments. Despite measurements being taken by an LPN and reported to the DNS, no follow-up actions or physician notifications were made, resulting in the ulcer deteriorating to a Stage 3 condition.
The facility did not conduct annual performance reviews for five CNAs, despite the expectation that these reviews occur annually. This was confirmed by the Interim Administrator during a review of personnel records.
The facility failed to ensure accurate daily staff postings for 7 out of 30 days, risking inaccurate staffing information for residents, the public, and staff. The Direct Care Staff Daily reports were incomplete, missing details such as census, staff numbers, and hours worked. The Administrator and Corporate Consultant acknowledged the issue, with the Administrator expecting staff to complete the sheets at the start of each shift.
The facility did not maintain appropriate medication storage temperatures, as temperature logs for a medication refrigerator were found blank on several dates. This oversight was acknowledged by the DNS, who stated that nurses were expected to complete these logs, potentially risking medication efficacy.
A resident with a history of shoulder pain experienced a lack of dignity and respect when an LPN failed to heed her expressed discomfort during a care procedure. Despite the resident's cognitive awareness and communication of pain, the LPN continued to lift the resident's arm, causing significant discomfort. The facility's investigation confirmed that the LPN was in a hurry and did not adhere to the resident's care plan, which emphasized avoiding rushing and listening to the resident.
A facility failed to provide a timely Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) to a resident with metabolic encephalopathy and COPD. The resident, who was cognitively intact, did not receive the SNF ABN until well after their last covered day of Medicare Part A services. The Social Services Director confirmed the delay, acknowledging the notice should have been issued on or before the last covered day, while the administrator noted a 48-hour notice is standard.
The facility failed to provide timely incontinence care for two residents, leading to delays in personal hygiene assistance. One resident, with heart failure and diabetes, experienced typical wait times of two hours for care despite using the call light. Another resident, with hepatic encephalopathy, waited over 90 minutes for assistance due to CNA confusion over room assignments. The interim administrator emphasized the expectation for prompt care and response to call lights.
Failure to Discontinue PRN Psychotropic Medications After 14 Days
Penalty
Summary
The facility failed to discontinue PRN psychotropic medication orders after 14 days for one resident who was admitted with diagnoses of dementia and depression. The resident had physician orders for PRN psychotropic medications, including quetiapine fumarate, prochlorperazine maleate, and hydroxyzine HCl, but there was no evidence in the medical record that the physician documented a rationale for extending the use of these medications beyond 14 days or evaluated the continued need for them since admission. A pharmacy review later recommended discontinuation of the PRN psychotropics due to non-use. Additionally, a staff member stated she was unaware of the 14-day limitation for PRN psychotropic medications and acknowledged that the orders had continued past the required timeframe without proper physician evaluation or documentation.
Failure to Assess and Supervise Residents for Smoking Safety
Penalty
Summary
The facility failed to assess and supervise residents for smoking safety as required by its own policies, resulting in deficiencies for two of three sampled residents. One resident, admitted with chronic obstructive pulmonary disease and deemed cognitively intact, was listed as an independent smoker but had no documented smoking assessment in the clinical record. This resident was observed disposing of a cigarette improperly and reported never being assessed or observed for smoking safety, despite being provided the facility's smoking policy only recently. Staff confirmed that, per policy, a smoking assessment should have been completed upon admission, but no evidence of such an assessment was found. Another resident, admitted with vascular dementia and care planned for supervised smoking, was found with cigarettes stored in their personal belongings rather than in the medication room as required. This resident was observed entering the smoking area independently, possessing smoking supplies, and smoking without staff supervision, with another resident lighting the cigarette. Staff interviews confirmed that the resident required supervision and that supplies should have been secured by staff, but these procedures were not followed. The lack of supervision and improper storage of smoking materials were acknowledged by facility staff.
Failure to Follow Physician's Orders for Oxygen Administration
Penalty
Summary
The facility failed to adhere to physician's orders regarding oxygen administration for five residents, leading to potential respiratory complications. Resident 13, diagnosed with chronic respiratory failure and heart failure, was observed receiving oxygen at 2 liters per minute instead of the prescribed 1 liter per minute. Similarly, Resident 15, with COPD and emphysema, was found to be on room air or receiving 1.5 liters per minute, contrary to the order for 2 liters per minute. Resident 16, who had acute respiratory failure and a transient cerebral ischemic attack, was receiving 1.5 liters per minute instead of the ordered 1 liter per minute, with staff failing to document the oxygen levels accurately. Resident 17, admitted with congestive heart failure and acute respiratory failure, was receiving oxygen at 2.5 liters per minute despite having no physician orders for oxygen. Lastly, Resident 19, with COPD and dysphagia, was administered oxygen at 1.5 liters per minute instead of the prescribed 2 liters per minute. In all cases, staff acknowledged the discrepancies between the physician's orders and the actual oxygen administration, indicating a systemic issue in following prescribed respiratory care protocols.
Failure to Provide Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure a resident received appropriate pressure ulcer treatments, resulting in the worsening of the resident's condition. Resident 4, who was admitted in 2017 with diagnoses including hypertension and diabetes, had a dressing on their right ankle dated 12/27/23. On that date, Staff 8, an LPN, measured the wound and provided the measurements to Staff 12, the former Director of Nursing Services (DNS). However, there was no follow-up notification to the physician, and no treatment orders were put in place for the pressure ulcer. By 1/3/24, during wound rounds with an outside wound care provider, it was discovered that the dressing was saturated, and the wound had deteriorated to a Stage 3 pressure ulcer, measuring 2 cm x 2.5 cm x 0.3 cm. Staff 12 acknowledged that no treatments were implemented from 12/27/23 through 1/3/24, and the wound care was not followed up on, leading to the worsening of the wound. The facility identified this as a deficiency in care provided to the resident.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received annual performance reviews, as evidenced by the lack of completed reviews for five randomly selected CNAs. These CNAs, identified as Staff 14, 18, 19, 20, and 21, were hired on various dates ranging from 2004 to 2021. Despite the expectation set by the Interim Administrator, Staff 2, that annual performance reviews should be conducted, none were completed for these staff members. This oversight was confirmed during a review of facility personnel records and an interview with Staff 2, who acknowledged the deficiency.
Inaccurate Daily Staff Postings
Penalty
Summary
The facility failed to ensure the accuracy of daily staff postings for 7 out of 30 days reviewed, which posed a risk to residents, the public, and staff due to the lack of accurate staffing information. The Direct Care Staff Daily reports, provided for the period from May 7, 2024, through June 10, 2024, revealed instances where portions of the forms were left blank or incomplete. Specifically, the incomplete information included the census, the number of staff working, and the number of hours worked. On June 14, 2024, during an interview, the Administrator and Corporate Consultant acknowledged the incompleteness of the reports for the specified days. The Administrator stated that it was her expectation that staff complete the daily staffing sheets at the beginning of each shift every day.
Failure to Maintain Medication Refrigerator Temperature Logs
Penalty
Summary
The facility failed to ensure appropriate medication storage temperatures were logged and maintained for a medication storage refrigerator. During an observation on June 13, 2024, it was noted that the temperature logs for the medication refrigerator were blank on multiple dates, including May 3, 10, 11, 12, 13, 18, 19, 20, 21, 26, 27, 28, 31, and June 1, 2, 3, 4, and 9, 2024. This oversight placed residents at risk for receiving medications with reduced efficacy. Staff 2, identified as the Director of Nursing Services (DNS), acknowledged the blank temperature logs and stated that the expectation was for the nurse to complete these logs.
Failure to Respect Resident's Dignity and Pain Management
Penalty
Summary
The facility failed to treat a resident with dignity and respect, as evidenced by an incident involving a Licensed Practical Nurse (LPN) who did not heed the resident's expressed pain during a routine care procedure. The resident, who was cognitively intact and had a history of shoulder pain, informed the LPN that lifting her arm caused significant discomfort. Despite this, the LPN continued with the procedure, which involved removing the resident's jacket, taking her blood pressure, and applying a lidocaine patch. This disregard for the resident's expressed pain and discomfort was documented in a facility investigation. The resident had previously communicated her shoulder pain to the staff, emphasizing her desire to avoid having her arm pulled. The LPN admitted to forgetting about the resident's shoulder pain and acknowledged being in a hurry during the incident. The resident's care plan, which advised staff to avoid rushing and to listen actively to the resident, was not followed. The Interim Administrator confirmed that the LPN did not slow down and failed to listen to the resident, which resulted in unnecessary pain for the resident.
Failure to Timely Provide SNF ABN Notice
Penalty
Summary
The facility failed to provide a written Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) in a timely manner for one resident reviewed for Beneficiary Protection Notification. The resident, who was admitted with diagnoses including metabolic encephalopathy and chronic obstructive pulmonary disease, was cognitively intact and responsible for their own decisions. The resident's last covered day of Medicare Part A services was on April 22, 2024, but the SNF ABN, Form CMS-10055, was not issued until June 11, 2024. This delay was confirmed by the Social Services Director, who acknowledged that the notice should have been provided on or before the last covered day. The facility administrator also stated that residents should be given a 48-hour notice of changes in coverage.
Delayed Incontinence Care for Two Residents
Penalty
Summary
The facility failed to provide timely incontinence care for two residents, leading to delayed assistance with personal hygiene. Resident 30, who was admitted with acute systolic heart failure and type two diabetes mellitus, was frequently incontinent and required extensive assistance for toileting. Despite using the call light to request incontinence care, Resident 30 experienced delays, with reports indicating a typical wait time of approximately two hours. Witnesses observed multiple CNAs entering the room without providing care, and the facility's administrator acknowledged awareness of complaints regarding long call light response times. Similarly, Resident 56, diagnosed with hepatic encephalopathy, required extensive assistance with toileting and bed mobility. On one occasion, after pressing the call light for assistance, Resident 56 waited over 90 minutes before receiving help, despite informing a CNA of the need for care. The CNA assigned to Resident 56 did not provide timely care due to confusion over room assignments. The interim administrator stated that resident care should be provided promptly, and staff should respond to all call lights regardless of room assignments.
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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