Glisan Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Portland, Oregon.
- Location
- 9750 Ne Glisan Street, Portland, Oregon 97220
- CMS Provider Number
- 385136
- Inspections on file
- 32
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Glisan Post Acute during CMS and state inspections, most recent first.
Surveyors found that kitchen equipment and food preparation areas were not maintained in a clean and sanitary manner, with visible dust, debris, grease, and food particles on multiple surfaces and storage areas. Staff interviews revealed a lack of routine cleaning protocols and documentation, and both the Dietary Manager and Administrator acknowledged the need for significant improvement in kitchen cleanliness.
A resident with chronic pain did not receive scheduled doses of oxycodone due to the facility's failure to reorder the medication in a timely manner. The pharmacy had notified the facility of the need for new orders, but delays in obtaining these orders led to missed doses, impacting the resident's pain management.
The facility failed to maintain sanitary conditions in dining services, with moldy ice scoop storage and unclean ice machine equipment. In the kitchen, opened and undated food items, expired products, and improper glove use during meal preparation were observed, violating food handling protocols.
The facility failed to ensure a clean and homelike environment in a shower room on the TCU, with issues such as black substance on floorboard edging, cracked flooring, and a dirty fan. Additionally, two residents had wheelchair armrests in disrepair, with torn coverings and peeling tape, making them uncleanable. Staff confirmed these deficiencies.
A resident with a fracture and schizophrenia reported missing clothing after staff took it to the laundry. Despite informing several staff members, no grievance process was initiated. The Housekeeping Supervisor was unaware, and a CNA did not report the issue. The DON stated that staff should check the inventory and start a grievance if items were not found, but this was not done.
A resident with hemiparesis and hemiplegia, who was moderately cognitively impaired and had difficulty hearing, did not receive appropriate communication support in their preferred language, Vietnamese. The facility failed to provide necessary communication aids, such as cue cards, and the translation service was non-functional. Staff interviews revealed a lack of awareness and use of these aids, and the resident's care plan was missing interventions for their hearing impairment.
A resident with neuromuscular dysfunction of the bladder did not receive adequate bathing assistance as per their care plan. The resident was scheduled for showers twice a week but was not consistently offered them, and refusals were not properly documented or reoffered. Staff interviews revealed inconsistencies in following the facility's protocol for reoffering showers, leading to unmet hygiene needs.
Two residents in an LTC facility did not receive person-centered activities, leading to a deficiency. One resident, with cognitive impairments, was not engaged in any activities despite expressing interest in reading and outings. Another resident, with hemiparesis, faced language barriers and lacked suitable materials, preventing participation in preferred activities. Staffing changes and lack of awareness of residents' preferences contributed to the deficiency.
A resident with chronic pain and opioid dependency was improperly administered oxycodone, as the facility failed to follow physician orders. The resident received 10 mg of oxycodone for moderate pain and 5 mg for severe pain, contrary to prescribed parameters, risking ongoing pain or over-sedation.
A resident at risk for pressure ulcers was not provided with a suitable cushion for their wheelchair, leading to skin irritation and breakdown. Despite repeated requests and staff acknowledgment of the need for a cushion, the resident continued to sit on a folded towel, highlighting a failure in implementing necessary interventions.
Two residents in a LTC facility did not receive appropriate care to prevent further decreases in range of motion. One resident with hemiparesis and hemiplegia lacked consistent application of a care plan involving a palm guard and therapy carrot. Another resident with dementia and left-sided weakness had no evidence of assessment or support for contracture management. Staff interviews revealed confusion and lack of coordination in implementing restorative programs.
A resident with PTSD and a history of trauma was admitted to a facility, but their care plan for PTSD was delayed by 38 days, leaving them without appropriate interventions. The resident experienced anxiety and night terrors, with known triggers not addressed in the care plan. Staff interviews revealed a lack of awareness and communication about the resident's needs, leading to inadequate trauma-informed care.
A resident with PTSD and stimulant abuse was not provided necessary behavioral health services, including counseling or peer support, in a LTC facility. The resident's care plans were not person-centered, and staff were unaware of the resident's anxiety attack and lack of individualized care. The resident expressed dissatisfaction with the facility's support for their PTSD and anxiety.
A resident with specific food preferences and dislikes was repeatedly served meals containing items they disliked, such as green beans and gravy, despite these preferences being documented. The dietary staff, including the cook and Dietary Director, acknowledged the resident's preferences but failed to adhere to them, leading to the resident refusing meals. The facility administrator acknowledged the findings without providing further information.
A resident with cognitive impairment sustained a second-degree burn after being served excessively hot coffee, which was taken out of the kitchen before cooling to a safe temperature. The incident occurred when an agency CNA found the resident had spilled the hot coffee on their lap, leading to a burn on the thigh. Dietary staff confirmed the coffee was brewed too hot, and the facility administrator acknowledged the premature removal of the coffee cart.
Failure to Maintain Sanitary Kitchen Conditions
Penalty
Summary
Surveyors observed that the facility failed to maintain kitchen equipment and food preparation areas in a clean and sanitary condition, as required by professional standards and the facility's own policy. During a kitchen inspection, numerous sanitation issues were identified, including a fan blowing into the food prep area with visible dust and debris, ovens with hard coatings and burnt substances, a grill with grease and food build-up, and floors and walls with various spills, sticky substances, and black debris. Bulk food bins and their surrounding areas were found with food particles and spills, and clean dishware storage areas had food particles in contact with clean items. Cooking utensils were stored in drawers with sticky spills, and the majority of the kitchen flooring and baseboards had significant debris and residue. Interviews with dietary staff revealed a lack of awareness regarding routine cleaning protocols and documentation requirements. Staff reported that each person was responsible for cleaning their own area, but there was no formal system or documentation in place to ensure compliance. The Dietary Manager, who was new to the position, confirmed that the kitchen did not meet cleanliness expectations, and the Administrator acknowledged the need for significant improvement in kitchen sanitation.
Failure to Timely Reorder Medication Results in Missed Doses
Penalty
Summary
The facility failed to reorder a medication in a timely manner, resulting in missed doses for a resident with chronic pain. The resident was admitted in May 2022 and had a physician order for 5 mg of oxycodone to be administered three times a day for pain management. However, the resident did not receive the scheduled evening dose on December 4, 2024, and the morning dose on December 5, 2024, due to the lack of a refill and the need for new physician orders. The pharmacy had informed the facility on December 2, 2024, that no refill was available, and new orders were required. Despite this, the new physician orders were not placed until December 4, 2024, at 9:00 PM, after the resident's supply was depleted. Staff confirmed that the medication was requested to be refilled when ten doses remained, but the delay in obtaining new orders led to the missed doses. The resident reported the missed doses and was informed that the medication was unavailable due to the need for new orders.
Sanitation and Food Handling Deficiencies
Penalty
Summary
The facility failed to maintain sanitary conditions in its dining services, specifically concerning the handling and storage of ice. Staff 21, a CNA, was observed using an ice scoop stored in a white mesh bag with visible mold growth to serve ice to residents. The ice scoop holder mounted on the wall near the ice machine was also found to be unclean, with black, slimy debris. Staff 14, the Housekeeping Supervisor, confirmed the container was not clean and was unsure of the cleaning frequency. The Administrator acknowledged the expectation for clean ice scoop containers. In the kitchen, the facility did not adhere to its food preparation and service policy. Several opened and undated food items were found in the dry storage area, including French onions, vinegar, and various seasoning mixes. Additionally, expired items such as horseradish and mayonnaise were present, along with items whose expiration dates could not be determined. In the walk-in freezer, a large chunk of ice was positioned above an open box of corn, and freezer-burned asparagus and an open bag of bratwurst were observed. Staff 15, the Dietary Director, acknowledged that these items should be discarded. During the lunch tray line service, Staff 25, a cook, failed to change gloves between tasks, despite handling various surfaces and food items. The cook was observed opening drawers and the freezer door, retrieving food, and plating meal trays without changing gloves. When questioned, Staff 25 incorrectly stated that gloves were changed after touching doors. Staff 15 later confirmed that staff were expected to change gloves between tasks, indicating a lapse in adherence to the facility's food handling protocols.
Facility Fails to Maintain Clean Environment and Equipment
Penalty
Summary
The facility failed to maintain a clean and homelike environment in one of the three shower rooms on the Transitional Care Unit (TCU). Observations made over several days revealed that the shower had a black substance along the metal floorboard edging, deep cracks with black substance in the flooring, and a dirty overhead fan that emitted a loud grinding noise. The Housekeeping Supervisor confirmed that the shower's floorboard was rusted and uncleanable, the flooring was cracked, and the fan was dirty, acknowledging that the shower was not clean or homelike. Additionally, the facility did not ensure that residents' personal equipment was in good repair. Two residents were observed with wheelchair armrests in disrepair; one had a torn covering with exposed foam, and the other had black tape peeling back, making the surfaces uncleanable. The Maintenance Assistant confirmed that these issues had been reported to the maintenance department, and the Director of Nursing Services acknowledged the poor condition of the wheelchair armrests.
Failure to Initiate Grievance Process for Missing Personal Property
Penalty
Summary
The facility failed to initiate a grievance process for a resident who reported missing personal property. The resident, admitted with a displaced intertrochanteric fracture of the left femur and schizophrenia, stated that after arrival, staff took their clothes to the laundry and did not return them. Despite informing several staff members about the missing clothing, no grievance process was initiated. The resident's inventory sheet confirmed the admission with specific clothing items. The Housekeeping Supervisor was unaware of the missing items, and a CNA acknowledged the resident's complaint but did not report it. The Director of Nursing stated that staff should check the inventory sheet and initiate a grievance if items were not found, but this procedure was not followed.
Failure to Provide Communication Support for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide appropriate communication treatment and services for a resident with hemiparesis and hemiplegia following a stroke, who was moderately cognitively impaired and had moderate difficulty hearing. The resident's preferred language was Vietnamese, and they required an interpreter to communicate with healthcare staff. Despite these needs being documented in the resident's care plan, the facility did not provide the necessary communication aids, such as cue cards, and the phone number for the translation service was non-functional. Observations revealed that the resident was unable to effectively communicate with staff, as they could only nod in response to basic questions and were not aware of the communication aids that should have been available. Interviews with staff indicated a lack of awareness and use of the translation services and communication aids specified in the resident's care plan. Staff members admitted to not using a translator and were unaware of the availability of cue cards or boards for the resident. Additionally, the resident's care plan was missing necessary interventions related to their hearing impairment, and the picture board that was initially provided was not replaced after it went missing. This lack of adherence to the care plan and failure to provide appropriate communication support placed the resident at risk for diminished quality of life and potential decline in their ability to perform activities of daily living.
Failure to Provide Adequate Bathing for Resident
Penalty
Summary
The facility failed to provide adequate bathing for a resident who was dependent on staff assistance for showers. The resident, who was cognitively intact and had a diagnosis of neuromuscular dysfunction of the bladder, was scheduled to receive showers on Monday and Friday evenings. However, documentation revealed that the resident was not offered showers on several scheduled days, and when the resident refused a shower, there was no evidence that the staff reoffered the shower or reported the refusal to a nurse. The resident expressed dissatisfaction with the frequency of showers, stating that staff were often too busy or offered showers at inconvenient times without prior notice. Interviews with staff members revealed inconsistencies in the implementation of the facility's policy regarding reoffering showers. Some staff admitted to not having time to assist the resident with showers if the resident agreed late in the shift, while others indicated that showers were offered at times when the resident was likely to refuse. The Director of Nursing Services confirmed the lack of documentation for reoffering showers and acknowledged the failure to adhere to the facility's protocol for handling shower refusals.
Failure to Provide Person-Centered Activities
Penalty
Summary
The facility failed to provide an ongoing person-centered activity program for two residents, leading to a deficiency in meeting their psychosocial needs. Resident 36, admitted with diagnoses including cardiomyopathy, dementia, restlessness, and anxiety disorder, expressed a desire to participate in various activities such as reading, puzzles, and outings. However, from October 20 to November 20, 2024, Resident 36 did not participate in any activities, as confirmed by activity logs and staff interviews. Observations revealed the resident was often in bed with no engagement in activities, and staff were unaware of the resident's preferences. Similarly, Resident 9, with a history of hemiparesis and hemiplegia following a stroke, was moderately cognitively impaired and preferred activities such as listening to Vietnamese music, reading, and participating in group activities. Despite these preferences, Resident 9 did not engage in any activities from October 21 to November 19, 2024. The resident reported language barriers and a lack of suitable materials and activities, such as large print newspapers and Vietnamese music, which hindered participation. Staff interviews indicated a lack of awareness of the resident's preferences and needs. The deficiency was further compounded by staffing issues, as the previous activity director left in September 2024, and the new director started in November 2024, resulting in minimal activities being offered. The activities assistant, working part-time, focused on familiar residents, neglecting others like Residents 36 and 9. The facility's failure to provide individualized and meaningful activities for these residents led to a decline in their psychosocial well-being and quality of life.
Failure to Follow Physician Orders for Pain Management
Penalty
Summary
The facility failed to adhere to physician orders for a resident with chronic pain and opioid dependency, leading to improper administration of oxycodone. The resident was prescribed 10 mg of oxycodone for severe pain rated between 7 to 10 on a pain scale and 5 mg for moderate pain rated between 4 to 6. However, the medication administration record (MAR) for November 2024 showed that the resident received 10 mg of oxycodone on four occasions when their pain was documented as 5 or 6, which was outside the prescribed parameters. Additionally, the resident was administered 5 mg of oxycodone on two occasions when their pain was documented as 7, which also did not align with the physician's orders. The Director of Nursing Services (DNS) confirmed these discrepancies upon reviewing the MAR, acknowledging that the resident received oxycodone outside of the physician's ordered parameters. This failure placed the resident at risk for ongoing pain or over-sedation.
Failure to Provide Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement necessary interventions to prevent pressure ulcers and skin breakdown for a resident who was at risk for such conditions. The resident, who was admitted with neuromuscular dysfunction of the bladder, was cognitively intact and identified as at risk for developing pressure ulcers. The resident's physician orders required wound care for skin tears on the thighs, and the resident was supposed to have a pressure-reducing device for the wheelchair. However, the resident was observed sitting on a folded towel instead of a proper cushion, which was necessary to prevent skin irritation and breakdown. Despite the resident's repeated requests for a suitable cushion, the facility failed to provide one that met the resident's needs. Staff members, including CNAs and an RN, acknowledged that the resident should have a cushion when in the wheelchair and confirmed the resident's complaints of discomfort. The DNS reviewed the resident's clinical record and confirmed the resident's risk for pressure ulcers, yet the appropriate intervention of providing a suitable cushion was not implemented, leading to the deficiency.
Failure to Provide Appropriate ROM Care
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent further decreases in range of motion for two residents, leading to a deficiency in care. Resident 9, who was admitted with hemiparesis and hemiplegia following a stroke, was observed to have contractures on the left side. Despite having a care plan that included the use of a left hand palm guard and therapy carrot, as well as daily range of motion exercises, documentation revealed that these interventions were not consistently applied. Observations showed that the resident's left hand was often without the necessary splint or brace, and staff interviews indicated a lack of clarity and consistency in implementing the resident's restorative program. Resident 10, who was readmitted with dementia and left-sided weakness, also experienced a lack of appropriate care for contracture management. The resident's clinical record lacked evidence of comprehensive assessment, ongoing monitoring, or any support or exercises to maintain or improve range of motion. Observations and staff interviews confirmed that the resident did not participate in any range of motion exercises and did not have any devices like a therapy carrot, splint, or brace for the left hand. Staff were unaware of any restorative program for the resident, and there was no care plan related to the management of the resident's upper extremity contractures. The deficiency was further highlighted by the lack of communication and coordination among staff members regarding the residents' care plans and restorative programs. Staff interviews revealed confusion about responsibilities and the absence of clear documentation to indicate whether restorative activities were offered or completed. The Director of Rehab confirmed that no referral had been received for Resident 10, and the Director of Nursing Services acknowledged the lack of assessment and care planning for the resident's contractures.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care to a resident who was a trauma survivor, leading to a deficiency in care. The resident, who had a history of PTSD and stimulant abuse, was admitted to the facility with significant trauma history, including a motor vehicle accident that resulted in paraplegia and the death of a child. Despite the facility's policy to screen for trauma and develop a care plan based on the resident's needs, the care plan for the resident's PTSD was not developed until 38 days after admission. This delay in care planning left the resident without appropriate interventions for managing PTSD symptoms and potential triggers. The resident experienced frequent anxiety and night terrors related to their PTSD, which were not adequately addressed by the facility. The resident reported various triggers, such as loud noises and certain television shows, which exacerbated their anxiety. Despite these known triggers, the care plan did not include specific interventions to mitigate these issues, and staff were not fully informed about the resident's needs. The resident also experienced an anxiety attack when their room became crowded and loud, further highlighting the lack of a comprehensive care plan. Interviews with staff revealed a lack of awareness and communication regarding the resident's PTSD and anxiety triggers. The Social Services Director had not conducted a thorough follow-up assessment since the resident's admission, and the Director of Nursing Services confirmed the care plan was incomplete. Staff members were unaware of the resident's night terrors and anxiety attacks, indicating a failure to provide consistent and informed care. This lack of trauma-informed care placed the resident at risk for re-traumatization and decreased their quality of life.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident diagnosed with PTSD and stimulant abuse. The resident, who was admitted in September 2024, had a history of a traumatic motor vehicle accident resulting in paraplegia and experienced PTSD symptoms such as night terrors and panic attacks. Despite these needs, the facility did not offer the resident mental health services, peer support, or participation in Narcotics Anonymous meetings, nor did they assist with obtaining the Affect App, which could aid in addiction recovery. The resident's care plans were not person-centered and did not accurately reflect the resident's behaviors or needs. The behavior care plan included interventions for behaviors the resident did not exhibit, such as yelling and crying, and the psychosocial-emotional care plan lacked individualized strategies to address the resident's PTSD and anxiety. The facility's social services director admitted to not having asked the resident about their interest in additional mental health support beyond an initial inquiry at admission. On November 19, 2024, the resident received a PRN medication for anxiety, but there was no documentation explaining the cause of the anxiety or any non-pharmacological interventions attempted. Staff members, including the social services director and the director of nursing services, were unaware of the resident's anxiety attack and the lack of person-centered care planning. The resident expressed dissatisfaction with the facility's lack of support for their PTSD and anxiety, stating that they had not been offered counseling or therapy services since admission.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to accommodate the food preferences of a resident, identified as Resident 37, who was admitted with neuromuscular dysfunction of the bladder and was cognitively intact. Upon admission, the resident expressed specific food preferences, including a dislike for peas, green beans, pepper, raisin bread, and raisins, and a preference for oatmeal for breakfast and a salad with meals. Despite these documented preferences, the resident was repeatedly served meals containing disliked items such as green beans and gravy, and was not provided with the requested salad. On multiple occasions, the resident was observed refusing meals due to the presence of disliked items, such as green beans and gravy, which were not supposed to be included according to the resident's meal ticket. The dietary staff, including the cook and the Dietary Director, acknowledged the resident's preferences but failed to adhere to them. The cook admitted to serving beef coated in gravy despite knowing the resident's dislike for it, and the Dietary Director confirmed that the resident should not have been served such meals. The facility administrator acknowledged the findings but did not provide additional information.
Failure to Prevent Access to Excessively Hot Liquids
Penalty
Summary
The facility failed to ensure that cognitively impaired residents did not have access to excessively hot liquids, resulting in a second-degree burn for one resident. The incident involved a resident who was admitted with diagnoses including diabetes. On a specific date, an agency CNA notified an LPN that the resident had spilled hot coffee on their lap. A subsequent facility investigation revealed that the nursing staff had taken the coffee cart out of the kitchen before the coffee had cooled to a safe temperature, leading to the resident being served coffee that was too hot, above 155 degrees Fahrenheit. The resident was later assessed to have a second-degree burn on their right lateral thigh, characterized by a large area of reddened skin with several ruptured blisters and clear fluid drainage, and the resident reported experiencing pain. Interviews with dietary staff confirmed that the coffee was brewed too hot to serve and was supposed to cool before being served to residents. The facility administrator acknowledged that staff had prematurely taken the coffee cart out, resulting in the burn incident, and confirmed that there were no other incidents related to hot coffee temperatures since then. Staff members also stated that coffee temperatures were not checked prior to the incident.
Removal Plan
- Policy/procedure change related to coffee preparation.
- Audit for other potentially affected residents.
- All staff education related to hot liquid safety.
- Audits of new process for distributing hot beverages to ensure completion.
- Coffee machine brew temperature lowered.
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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