Gracelen Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Portland, Oregon.
- Location
- 10948 S.e. Boise, Portland, Oregon 97266
- CMS Provider Number
- 38E188
- Inspections on file
- 27
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Gracelen Care Center during CMS and state inspections, most recent first.
The facility failed to timely report suspected resident-to-resident physical abuse to the proper authorities. Two residents, one with major depressive disorder and another with senile degeneration of the brain with anxiety and agitation, were involved in an altercation in which one resident struck the other with a reader stick after the other entered the room looking for personal items. A progress note documented that a resident reported being hit by another resident and was observed receiving a bandage to the knee. The Social Services Director completed an incident report and informed the administrator and DNS around midday, but the FRI was not submitted until several hours later, exceeding the required 2-hour reporting timeframe acknowledged by the DNS.
A resident with end stage kidney disease and diabetes became lethargic and unable to take medications, but despite repeated reports from staff, the responsible nurse did not perform or document a timely assessment, obtain vital signs, check blood sugar, or notify the on-call provider. The resident was later sent to the hospital at the family's request and diagnosed with sepsis due to a urinary tract infection.
A resident with multiple risk factors for pressure injuries was admitted with a sacral wound, but staff failed to perform a comprehensive wound assessment, notify the provider, or initiate timely wound care. After hospitalization and return with wound care orders, prescribed treatments for the sacrum and heels were delayed or not provided, and staff interviews revealed lapses in assessment, documentation, and care initiation.
A deficiency was cited when an area of the facility was not kept free from accident hazards and adequate supervision was not provided to prevent accidents. The environment and supervision protocols were found to be insufficient to minimize accident risks.
The facility did not maintain RN coverage for eight consecutive hours on multiple days, as required, with staff and administrative acknowledgment of the deficiency. This resulted in a lack of appropriate RN presence to provide necessary care and assessments.
A resident was allegedly shoved into a wall by a roommate, and the incident was reported by a family member to facility staff. Despite being informed during shift change, an RN did not notify the State Agency of the abuse allegation and only reported it to the administrator and DNS after more than two hours. No report was made to the State Agency as required by policy.
A resident was moved to a new room after an altercation in which a former roommate allegedly shoved them into a wall. The incident was reported by a family member and known to staff, but a thorough investigation was not completed in accordance with the facility's abuse prevention policy.
Two residents with a history of stroke and dementia, both identified as high fall risks, were observed in bed without required fall mats in place. Staff interviews revealed a lack of awareness or failure to implement care plan interventions, and an LPN confirmed that the fall prevention measures were not followed as documented in the residents' care plans.
A resident with cognitive impairment and a history of falls was not provided with care planned fall prevention interventions, including a 'call don't fall' sign and a front wheel walker (FWW). Instead, the resident was observed ambulating with a wheelchair, and staff confirmed the absence of both the sign and the FWW, contrary to the care plan.
Three medication administration errors were observed, resulting in a 12% error rate. Two residents with diabetes did not receive insulin injections according to manufacturer instructions, as the LPN failed to hold the insulin pen in place for the recommended duration. Another resident prescribed Creon did not receive the medication with food, as required, because the CMA administered it without coordinating with meal times. The DNS confirmed that staff did not follow expected procedures.
Surveyors found an expired vial of tuberculin in the medication storage room refrigerator and observed that treatment carts containing medications and medical supplies, including insulin and needles, were left unlocked and unattended in two hallways. Staff and the DNS confirmed that these practices did not meet facility policy, which requires timely disposal of expired biologicals and that medication carts remain locked when not in use.
A resident with quadriplegia and multiple pressure ulcers received wound care from an LPN who failed to perform hand hygiene between glove changes, despite CDC guidelines requiring this practice. The LPN acknowledged only performing hand hygiene before and after the procedure, and the DON confirmed that hand hygiene should occur after glove removal during wound care.
A resident with vascular dementia and a hip fracture was threatened by a CNA for using the call light too much. The CNA told other staff to inform the resident they would be isolated without a call light if they continued. The incident was reported by two CNAs and confirmed by the resident, who experienced fear when the CNA turned off the lights. Management confirmed the occurrence.
A facility failed to document the reason for transferring a resident with traumatic brain injury and delirium to an acute care hospital and did not communicate necessary health information to the receiving provider. The resident's medical record lacked documentation on why the facility could not meet the resident's needs and whether the discharge was initiated by the resident or the facility. The DNS acknowledged the missing discharge information.
The Dietary Manager failed to obtain the required certification to provide dietary management services. The Dietary Manager, who had been in the position since 4/2022, was observed providing services without the necessary certification. The Administrator confirmed awareness of this issue.
The facility failed to protect residents from physical abuse, with multiple incidents involving residents with severe cognitive impairments physically assaulting each other. These incidents were witnessed by staff and confirmed by the facility administrator, highlighting a lack of adequate supervision and intervention.
The facility failed to ensure nursing staff competencies for five staff members, placing residents at risk for poor quality of care. Incomplete or missing competency records were found for an RN and four other nursing staff members during a survey.
The facility failed to ensure that CNAs received their annual performance reviews, placing residents at risk for lack of care by competent staff. Personnel records showed that four CNAs had not received their evaluations, and the DNS confirmed awareness of this issue.
The facility failed to ensure proper infection control practices during medication administration and dining. An RN did not disinfect a glucometer or perform hand hygiene between residents, a CMA did not wash hands between handling medications for different residents, and a CNA did not change gloves or perform hand hygiene while assisting multiple residents with eating. The DNS acknowledged these lapses in infection control.
The facility failed to ensure that CNA staff received the required 12 hours of in-service training annually. Four out of five randomly selected CNAs did not meet the training requirements, with one completing 8.6 hours, another 0 hours, a third 9.10 hours, and the fourth 4 hours. The DNS confirmed the lack of compliance and acknowledged awareness of the issue.
The facility failed to maintain a homelike environment, with issues such as missing cove base, scrapes of missing paint, gouges of missing wood, and torn floor mats in resident rooms. The west hall sitting area and west dining room also had peeling wall coverings, cracks, and exposed screws, creating an unkempt environment.
The facility failed to report an incident of suspected abuse in a timely manner for two residents diagnosed with dementia. The residents were involved in an altercation where they were overheard yelling and observed hitting each other. The incident was not reported within the required two-hour timeframe, placing residents at risk for abuse.
The facility failed to ensure residents were treated with dignity during meal times, as staff members were observed standing while assisting residents with eating. Both a CNA and an RN acknowledged the lack of available stools as the reason for standing, despite knowing it was against policy.
The facility failed to obtain consent before administering psychotropic and antiviral medications to two residents. One resident with Alzheimer's disease received mirtazapine and quetiapine without documented consent, while another resident with anxiety and depression received clonazepam, Celexa, and asenapine without documented consent. Staff confirmed the lack of documentation and consent for these medications.
A resident with Parkinson's disease experienced leg pain due to exposed metal on her/his wheelchair and a missing arm rest pad. Despite the CNA reporting the issue to maintenance, the Maintenance Director was unaware, and the LPN Resident Care Manager observed indentations on the resident's calves, indicating a need for a cushion or wedge.
The facility failed to obtain consent, assess, monitor, and reevaluate the use of bolster pillows as restraints for a resident with severe cognitive impairment. Staff confirmed the use of pillows to prevent falls but acknowledged the lack of consent and proper documentation, placing the resident at risk for inappropriate restraint use.
A resident with schizoaffective disorder, bipolar disorder, and stroke was observed performing ADLs independently, despite their care plan indicating they required extensive assistance. Staff confirmed the resident's independence, but the care plan was not updated to reflect this, leading to a deficiency.
The facility failed to complete a discharge summary for a resident diagnosed with normal pressure hydrocephalus who initiated a discharge. The DNS was unable to provide the required documentation upon review.
The facility failed to follow physician orders for two residents, leading to unmet care needs. One resident did not receive prescribed medication for five days, and another resident's edema was not monitored as ordered. Staff and administration acknowledged these failures.
A resident with Alzheimer's disease was prescribed acyclovir without a clear indication, receiving the medication daily from January to April 2024. The medication was initially prescribed for chemotherapy that ended in August 2023, and staff later acknowledged it should not have been continued.
Failure to Timely Report Suspected Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to timely report an incident of suspected physical abuse between two residents to the proper authorities. Resident 6, admitted in 11/2024 with major depressive disorder, and Resident 7, admitted in 1/2026 with senile degeneration of the brain with anxiety and agitation, were involved in an altercation on 2/14/26 at 10:00 AM when Resident 7 struck Resident 6 with a reader stick after Resident 6 wandered into Resident 7’s room looking for personal items. A progress note entered on 2/14/26 at 12:28 PM documented that the Social Services Director (Staff 7) observed Resident 6 receiving assistance with a bandage to the knee, and upon inquiry, Resident 6 reported being hit by another resident after entering that resident’s room and approaching them. Staff 7 stated she completed an incident report regarding the event at approximately 12:00 PM on 2/14/26 and informed both the Facility Administrator (Staff 1) and the DNS (Staff 2) of the incident at that time. Despite this, the Facility Reported Incident (FRI) was not submitted until 2/14/26 at 6:27 PM, more than two hours after the facility became aware of the suspected abuse. On 3/10/26 at 12:26 PM, the DNS (Staff 2) acknowledged awareness of the incident and confirmed that allegations of potential abuse were required to be reported within two hours of occurrence, and further acknowledged that this incident was not reported within the required two-hour timeframe.
Failure to Timely Assess Change in Condition
Penalty
Summary
A deficiency occurred when staff failed to assess a resident's change of condition in a timely manner. The resident, who had end stage kidney disease and diabetes and was admitted with moderate cognitive impairment, was observed by multiple staff to be lethargic, difficult to rouse, and unable to take medications. Despite these observations and repeated reports from a CMA and CNA to the charge nurse, there was no documented evidence that a physical assessment, vital signs, or blood sugar checks were performed, nor was the on-call provider contacted. The only recorded vital sign was a blood pressure reading several hours after the initial concern, and the resident was ultimately sent to the hospital at the family's request. Interviews with staff confirmed that the expected protocol for a change in mental status—such as immediate assessment, obtaining vital signs, checking blood sugar, and notifying the provider—was not followed. The nurse responsible did not document any assessment or communication with the provider, and the on-call provider confirmed they were not notified. The resident was later found to have sepsis due to a urinary tract infection upon hospital admission. Facility leadership acknowledged the lack of assessment and documentation in this incident.
Failure to Assess and Treat Pressure Ulcers
Penalty
Summary
The facility failed to properly assess, monitor, and treat pressure ulcers for a resident admitted with significant risk factors, including end stage kidney disease, diabetes, decreased mobility, and incontinence. Upon admission, the resident was noted to have an unstageable sacral wound, but no comprehensive assessment was performed to document the wound's characteristics such as location, stage, measurements, tissue type, or other relevant details. There was also no evidence that the facility provider was notified of the wound, and no wound care or treatment was documented for the first six days following admission. Additionally, after the resident was hospitalized and returned with specific wound care orders for the sacrum and both heels, the facility failed to initiate or document the prescribed treatments in a timely manner. Treatment for the sacral wound was delayed by five days, care for the left heel was delayed by thirteen days, and there was no record of treatment for the right heel wound. Interviews with staff revealed confusion and lack of clarity regarding responsibilities for wound assessment, documentation, and initiation of care orders. Staff acknowledged that required assessments and treatments were not completed as expected, and the resident's wound condition did not improve during their stay.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for eight consecutive hours each day, seven days a week, as required. Review of Direct Care Staff Daily Reports for the specified periods revealed that on eight separate days, there was no RN coverage for the required duration on any shift within a 24-hour period. This deficiency was confirmed through both record review and staff interviews, with the staffing coordinator acknowledging the lack of adequate RN coverage on the identified dates. The administrator also confirmed the expectation for appropriate RN staffing to provide necessary care and assessments for residents.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
Facility staff failed to report an incident of potential abuse involving a resident who was allegedly shoved into a wall by a roommate. The family member of the affected resident immediately informed facility staff about the physical altercation. However, the registered nurse on duty did not notify the State Agency of the abuse allegation, despite being informed of the incident during shift change. The nurse subsequently reported the allegation to the facility administrator and director of nursing more than two hours after becoming aware of it. The administrator confirmed that no report was made to the State Agency regarding the incident, which was contrary to the facility's abuse prevention policy requiring all suspected or alleged cases of abuse to be reported within the mandated two-hour timeframe.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to conduct a thorough and timely investigation into an allegation of abuse involving a resident who was reportedly shoved into a wall by a former roommate. According to the facility's Abuse Prevention Policy, all suspected or alleged cases of abuse are to be investigated thoroughly and completed within five days. Documentation showed that the resident was moved to a new room following the altercation, and a family member reported the incident to staff immediately. Staff interviews confirmed that the incident was reported and known to staff, but the administrator acknowledged that a complete investigation was not conducted as required by policy.
Failure to Implement Fall Prevention Interventions for High-Risk Residents
Penalty
Summary
The facility failed to implement care plan interventions for two residents identified as high risk for falls. One resident, admitted with a history of stroke and anxiety, was assessed as a high fall risk and had a care plan intervention requiring a fall mat to be placed at the bedside when in bed. On multiple occasions, this resident was observed in bed without a fall mat present. Staff interviews confirmed that the care plan was not being followed, and staff were either unaware of the required interventions or acknowledged that they were not implemented. Another resident, admitted with dementia and stroke, also had a care plan indicating a high fall risk and the need for a fall mat when in bed. This resident was observed on two separate occasions sleeping in bed without a fall mat in place. Staff interviews revealed uncertainty or lack of knowledge regarding the resident's fall interventions, and the responsible care manager confirmed the absence of the fall mat and was unable to locate one in the resident's room. These failures resulted in the care plans not being implemented as written.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
A deficiency occurred when the facility failed to implement care planned interventions to prevent falls for a resident with cognitive impairment and a history of falls. The resident, diagnosed with fibromyalgia and admitted in January 2025, had multiple documented falls and was care planned to have a 'call don't fall' sign within eyesight and to use a front wheel walker (FWW) for ambulation. However, observations over several days revealed that the resident did not have the required sign posted in the room and was not provided with a FWW. Instead, the resident was seen using a wheelchair to ambulate to the restroom and reported not being offered a FWW. Interviews with staff confirmed the absence of the sign and the FWW, with multiple CNAs and an LPN stating that the resident was not given a FWW and that the sign was not present in the room. The Resident Care Manager acknowledged that the care plan required these interventions but was unaware that the resident was using the wheelchair for ambulation instead. These failures to follow the care plan placed the resident at risk for further falls and injury.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication administration error rate below 5%, with three errors identified in 25 observed opportunities, resulting in a 12% error rate. During medication administration, staff did not follow manufacturer instructions for insulin pen use for two residents with type 2 diabetes mellitus. Specifically, the LPN administered insulin injections and immediately removed the needle from the skin without holding it in place for the recommended 10 seconds, as specified by the manufacturer. The facility's own policy also did not align with manufacturer instructions, indicating a five-second hold, but this was not followed either. The DNS confirmed that staff did not adhere to the expected safety steps for insulin administration. Additionally, a resident prescribed Creon for digestive support did not receive the medication with food, as required by both manufacturer instructions and physician orders. The CMA administered Creon without offering a snack or meal, and no food was present in the resident's room at the time. The CMA stated that coordinating medication administration with meal times was challenging, and referenced the facility's policy allowing a one-hour window before and after scheduled medication times. The DNS acknowledged that staff were expected to follow physician orders regarding medication administration with meals.
Expired Biologicals and Unsecured Medication Carts Identified
Penalty
Summary
Surveyors observed that the facility failed to ensure proper storage and labeling of drugs and biologicals in accordance with professional standards. Specifically, an open vial of tuberculin used for tuberculosis testing was found in the medication storage room refrigerator past its expiration date. The Director of Nursing Services (DNS) confirmed that the vial was expired and acknowledged that staff are expected to discard such vials within 30 days of opening, as per facility policy. Additionally, treatment carts in both the East Hall and another hall were repeatedly found unlocked and unattended during multiple observations. These carts contained medications and supplies such as insulin, insulin pens, needles, oral medications, dressings, creams, and tube feeding medications. Staff, including LPNs and RNs, acknowledged that the carts should have been locked when not in use or when staff were not present. The DNS also confirmed the expectation that medication and treatment carts remain locked when unattended.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
A deficiency was identified when a staff member failed to perform hand hygiene during wound care for a resident with quadriplegia and multiple pressure ulcers. The resident had a history of four pressure ulcers upon admission and later developed an additional in-facility pressure ulcer. During observed wound care procedures, the LPN was seen removing and donning new gloves multiple times while providing care to wounds on the ischium and sacrum, but did not perform hand hygiene between glove changes as required by CDC guidelines. The LPN acknowledged performing hand hygiene only before and after the wound care treatments, not in between glove changes. The Director of Nursing Services confirmed that the expectation was for staff to perform hand hygiene after glove removal during wound care. This failure to follow proper hand hygiene protocol was observed and confirmed through staff interview and record review.
Failure to Protect Resident from Mental Abuse by CNA
Penalty
Summary
The facility failed to protect a resident's right to be free from mental abuse by staff, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident diagnosed with vascular dementia and a hip fracture. The resident, who was cognitively intact according to their Admission Minimum Data Set (MDS), was reportedly threatened by a CNA for using the call light excessively. The CNA allegedly told other staff members to inform the resident that they would be placed in a room alone with the door closed and without a call light if they continued to use it too much. This behavior was reported by two other CNAs who witnessed the incident and immediately informed management. The resident confirmed the incident, stating that they were indeed threatened and that the CNA had turned off the lights on one occasion, causing the resident to scream until the lights were turned back on. This incident was corroborated by the Director of Nursing Services (DNS) and the Administrator, who confirmed that the event occurred. The report highlights a failure in the facility's responsibility to protect residents from mental abuse, placing them at risk for further abuse.
Failure to Document Transfer Basis and Communicate Health Status
Penalty
Summary
The facility failed to document the basis for the transfer of a resident and did not include necessary information such as the code and health status to the receiving provider. This deficiency was identified during an interview and record review, which revealed that the facility did not document the reason for the transfer of a resident with traumatic brain injury and delirium to an acute care hospital. The resident's medical record lacked documentation indicating why the facility could not meet the resident's needs and whether the discharge was initiated by the resident or the facility. The Director of Nursing Services acknowledged the absence of discharge information in the resident's medical record.
Dietary Manager Lacks Required Certification
Penalty
Summary
The Dietary Manager failed to obtain the required certification to provide dietary management services. From 4/2/24 through 4/8/24, the Dietary Manager was observed providing services in the facility kitchen. On 4/5/24, the Dietary Manager stated he had been in the position since 4/2022 and had not completed the required certification. On 4/8/24, the Administrator confirmed awareness of the Dietary Manager's lack of certification.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by multiple incidents involving residents with severe cognitive impairments. Resident 26, diagnosed with dementia and behavioral disturbance, physically assaulted Resident 4, who is cognitively intact, by punching them on the shoulder and face. This incident was witnessed by an LPN and confirmed by the facility administrator. Additionally, Resident 3, with severe cognitive impairment, and Resident 18, with a moderate risk for aggressive behavior, were observed hitting each other after a verbal altercation. This incident was also confirmed by the facility administrator and witnessed by a CNA who intervened to separate the residents. Another incident involved Resident 3 and Resident 46, both with severe cognitive impairments. Resident 3 punched Resident 46 after the latter attempted to place a cup on Resident 3's bed, leading to a physical altercation where Resident 46 retaliated by hitting Resident 3. This incident was witnessed by housekeeping staff and confirmed by the facility administrator. Despite these incidents, Resident 3 was observed walking unsupervised throughout the facility, and Resident 46 was seen sitting in their room with the door open, indicating a lack of adequate supervision and intervention to prevent further abuse.
Failure to Ensure Nursing Staff Competencies
Penalty
Summary
The facility failed to ensure nursing staff competencies for five sampled staff members, which placed residents at risk for poor quality of care. During interviews and record reviews on 4/4/24 and 4/5/24, it was found that the facility could not provide complete competency reviews for Staff 14 (RN) and had no competency records for Staff 22 (LPN), Staff 23 (LPN), Staff 24 (RN), and Staff 25 (RN). Staff 2 (DNS) and Staff 27 (Staffing Coordinator) were unable to provide the requested evidence of competencies, and Staff 1 (Administrator) confirmed the lack of documentation.
Failure to Complete Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received their annual performance reviews, which placed residents at risk for lack of care by competent staff. Personnel records reviewed on April 5, 2024, with the Staffing Coordinator indicated that four CNAs (Staff 8, 17, 18, and 19) had not received their annual performance evaluations. Staff 8 had an adjusted seniority date of October 4, 2008; Staff 17, November 22, 2022; Staff 18, January 21, 2020; and Staff 19, October 9, 2021. The Staffing Coordinator confirmed the lack of completed annual performance reviews for these staff members. Additionally, the Director of Nursing Services (DNS) acknowledged awareness of the issue, confirming that many CNA staff, including the four mentioned, did not have their annual performance reviews completed.
Infection Control Deficiencies During Medication Administration and Dining
Penalty
Summary
The facility failed to ensure appropriate infection control practices during medication administration and dining, as observed in three staff members. One RN did not perform hand hygiene or disinfect a glucometer between uses for two residents, despite handling insulin and blood glucose monitoring supplies. The RN also failed to change gloves between residents and did not perform hand hygiene after removing gloves. This was confirmed by the RN, who admitted to not disinfecting the glucometer and misunderstanding glove use protocols. The DNS acknowledged the lack of appropriate infection control practices and stated the expected procedures for staff. Another staff member, a CMA, was observed administering medications without performing hand hygiene between residents. The CMA handled a resident's environment and medications with bare hands and did not wash hands before dispensing medications for another resident. The DNS was informed and acknowledged the lack of appropriate hand hygiene during medication administration. During a lunch meal observation, a CNA was seen repeatedly failing to perform hand hygiene between glove changes and while assisting multiple residents with eating. The CNA used the same gloves for different residents and did not wash hands after removing gloves. The CNA admitted to not consistently changing gloves between residents and not performing hand hygiene. The DNS confirmed that it was not acceptable for staff to wear the same gloves between residents and emphasized the importance of hand hygiene after removing dirty gloves and before putting on clean ones.
Failure to Ensure CNA Annual Training Compliance
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistant (CNA) staff received the required 12 hours of in-service training annually. This deficiency was identified for four out of five randomly selected staff members. Specifically, one CNA completed only 8.6 hours, another had 0 hours, a third had 9.10 hours, and the fourth had 4 hours of annual training. The Director of Nursing Services (DNS) confirmed the lack of compliance with the training requirements and acknowledged awareness that the CNA trainings were not being completed.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment, as observed from 4/2/24 through 4/8/24. Specific issues included a section of missing cove base behind the door, scrapes of missing paint along the wall under the window, gouges of missing wood on the window sill, and a bedside table base covered with paint chips in one resident's room. Additionally, floor mats in multiple resident rooms were torn and tattered. The west hall sitting area had a 12-inch piece of wall covering peeling from underneath the window sill, a long crack in the wall with missing paint above the hand hygiene dispenser, and four large screws sticking out of the wall below the flag quilt. The west dining room had an area on the north wall with missing paint and brackets sticking out. These issues were acknowledged by the Maintenance Director on 4/8/24 at 11:31 AM, indicating an unkempt environment for the residents.
Failure to Timely Report Suspected Abuse
Penalty
Summary
The facility failed to report an incident of suspected abuse in a timely manner for two residents diagnosed with dementia. Resident 3 and Resident 18, both admitted in December 2020, were involved in an altercation on July 22, 2022, where they were overheard yelling and observed hitting each other. The incident was not reported within the required two-hour timeframe, as confirmed by the Administrator on April 5, 2024. This delay in reporting placed residents at risk for abuse.
Failure to Ensure Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure residents were treated with dignity during meal times in the East dining room. Observations made during the lunch meal revealed that staff members were standing while assisting residents with eating, which is against the facility's policy. Specifically, a CNA was seen standing over one resident while assisting with eating and simultaneously assisting another resident. An RN also stood while assisting a third resident at the same table. Both staff members acknowledged that standing while assisting residents was not dignified and attributed their actions to a lack of available stools. Interviews with the CNA and RN confirmed that staff were aware of the policy requiring them to sit and be face-to-face with residents during meal assistance. The CNA and RN both stated that there were not enough stools for all staff members to sit while assisting residents. The Director of Nursing Services (DNS) also confirmed that standing while providing eating assistance was considered a lack of dignity and that staff were expected to sit when assisting residents with their meals.
Failure to Obtain Consent for Medications
Penalty
Summary
The facility failed to ensure consent was obtained prior to administering psychotropic and antiviral medications to two residents. Resident 29, who was admitted with Alzheimer's disease, received mirtazapine and quetiapine from December 2023 to April 2024 without documented consent from the resident or the resident's spouse, who was the responsible party. Staff 12 and Staff 2 confirmed the lack of documentation regarding the risks, benefits, and potential side effects of these medications, as well as the absence of consent prior to administration. Similarly, Resident 12, admitted with anxiety disorders and depression, received clonazepam, Celexa, and asenapine in March and April 2024 without documented consent. Staff 3 acknowledged the absence of documentation indicating that the resident was informed of the risks and benefits of these medications and confirmed that consent was not obtained before the medications were administered. This failure placed the residents at risk of being uninformed about their medications.
Failure to Provide Reasonable Wheelchair Accommodations
Penalty
Summary
The facility failed to provide reasonable accommodations for a resident with Parkinson's disease, who was observed sitting in a wheelchair with her/his calves pressed against exposed metal and a missing arm rest pad. The resident reported leg pain, and staff confirmed the issue but had not addressed it. The CNA had reported the missing arm rest pad to maintenance, but the Maintenance Director was unaware of the issue. The LPN Resident Care Manager observed indentations on the resident's calves due to the exposed metal and acknowledged the need for a cushion or wedge to prevent further discomfort.
Failure to Obtain Consent and Monitor Restraint Use
Penalty
Summary
The facility failed to obtain consent, assess, monitor, and reevaluate the use of bolster pillows as restraints for a resident diagnosed with schizophrenia and dementia with behavioral disturbances. The resident, who had severe cognitive impairment, was observed with four bolster pillows placed on either side of their upper and lower body to prevent falls. However, there was no documented consent from the resident's representative for the use of these pillows, nor was there any assessment, monitoring, or reevaluation conducted for their continued use. Staff confirmed that the bolster pillows were used to prevent the resident from falling out of bed but acknowledged that consent had not been obtained and that no assessments or monitoring had been performed. This lack of proper documentation and oversight placed the resident at risk for inappropriate use of restraints, as the facility did not follow its own policy requiring written physician orders, consent, and regular reviews for restraint use.
Inaccurate Care Plan for Resident's ADL Needs
Penalty
Summary
The facility failed to ensure that care plans were revised to accurately reflect the needs of a resident. Resident 8, who was admitted with diagnoses including schizoaffective disorder, bipolar disorder, and stroke, had a care plan indicating that they required extensive assistance for various activities of daily living (ADLs) such as toileting, dressing, personal hygiene, ambulation, bed mobility, and transfers. However, multiple observations over a week revealed that Resident 8 was independently performing these activities without assistance, contradicting the care plan's requirements. Staff interviews confirmed that Resident 8 was capable of completing most ADLs independently. A CNA reported that the resident only needed occasional checks and used a urinal that staff emptied. Another CNA stated that the resident changed their own brief and ambulated with a walker outside frequently. The LPN Resident Care Manager acknowledged that the care plan did not accurately reflect the resident's current level of ADL functioning. The Director of Nursing Services also expected the care plan to be accurate, indicating a failure in updating the care plan to match the resident's actual needs.
Failure to Complete Discharge Summary
Penalty
Summary
The facility failed to complete a discharge summary for a resident who was admitted in October 2023 with diagnoses including normal pressure hydrocephalus. The resident initiated a discharge from the facility on January 14, 2024. Upon review of the resident's health record, it was found that there was no discharge summary documentation. On April 8, 2024, the Director of Nursing Services (DNS) was unable to provide the required discharge summary documentation for the resident.
Failure to Follow Physician Orders for Medication and Monitoring
Penalty
Summary
The facility failed to follow physician orders for two residents, leading to unmet care needs. Resident 19, diagnosed with Huntington's disease and receiving hospice services, had an order for glycopyrrolate to control oral secretions. The medication was prescribed on 3/29/24 but was not administered until 4/3/24, five days later. This delay was confirmed by the Hospice RN, the LPN Resident Care Manager, and the facility's Administrator and DNS, who acknowledged the failure to implement the medication order in a timely manner. Resident 8, diagnosed with schizoaffective disorder, bipolar disorder, and stroke, had a physician order from 1/18/24 to monitor bilateral lower leg edema every 12 hours. However, there was no evidence in the resident's health record that this monitoring was conducted. On 4/2/24, the resident's lower legs and ankles were observed to be swollen. Staff, including an LPN and the LPN Resident Care Manager, confirmed that the monitoring was not performed as ordered. The DNS also acknowledged the failure to follow the physician's order for monitoring the edema.
Unnecessary Medication Prescribed to Resident
Penalty
Summary
The facility failed to ensure that residents were not prescribed unnecessary medications, specifically for one resident diagnosed with Alzheimer's disease. The resident was admitted in December 2023 and had a physician's order for acyclovir, an antiviral medication, starting in January 2024. The order did not specify the disease for which the medication was prescribed prophylactically, and no further information or rationale was provided. The resident received acyclovir daily from January to April 2024 without a clear indication for its use. On April 5, 2024, a Licensed Practical Nurse (LPN) questioned the use of acyclovir and consulted the physician, who then ordered the medication to be discontinued. The LPN and the Director of Nursing Services (DNS) later reviewed the resident's records and found that the acyclovir was initially prescribed in conjunction with chemotherapy that had ended in August 2023. They acknowledged that the medication should not have been ordered or administered beyond that date, resulting in the resident receiving unnecessary medication.
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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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