Green Valley Rehabilitation Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Eugene, Oregon.
- Location
- 1735 Adkins Street, Eugene, Oregon 97401
- CMS Provider Number
- 385156
- Inspections on file
- 22
- Latest survey
- February 2, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Green Valley Rehabilitation Health Center during CMS and state inspections, most recent first.
The facility did not maintain required RN coverage for at least eight consecutive hours per day on multiple days, as shown by review of Direct Care Staff Daily Reports over several months. Staff reported that the RN manager was only recently added to the staffing report, and the Administrator stated that staff were expected to call off two hours before their shift to allow time to find coverage. When surveyors requested payroll records to verify RN presence on the identified days, no additional documentation was provided, resulting in a cited deficiency for inadequate RN staffing.
A resident with depression and intact cognition reported missing jewelry, an oximeter, and art supplies to staff and during a resident council meeting, where residents had raised concerns about missing items. A CNA stated the resident had reported missing earrings and an oximeter and that she informed the charge nurse, but did not assist with another grievance form because the resident had already completed one. The facility’s grievance log showed no entry for this resident, and the Director of Social Services and Recreation could not locate or recall any grievance related to the missing items, suggesting it may have been lost amid staff confusion. The Administrator stated he would have expected staff to complete and resolve such a grievance within five days, but this did not occur, indicating the grievance process was not followed or tracked as required.
The facility failed to report an incident of potential neglect involving an elopement to the State Survey Agency. A resident with anxiety and a cognitive communication deficit was found off premises near a busy street after their wander guard device was not functioning. An internal elopement investigation identified confusion and device failure as the root causes, but no Facility Reported Incident (FRI) was submitted. The former administrator reported she would not report an elopement because it was no longer on the FRI form, and the current administrator confirmed that no FRI was completed, despite the regional RN’s expectation that an FRI be submitted for such an alleged violation.
A resident with severe cognitive impairment and a history of wandering had a care plan and TAR requiring a Wander Guard on the wheelchair and shift-by-shift checks of its placement and function, along with diversional interventions. Surveyors found no documentation that staff performed these required Wander Guard checks. The resident subsequently eloped and was found confused and in a precarious position near a busy street, and staff reported the resident did not have a Wander Guard on the wheelchair at that time. Although 15-minute checks were ordered after the elopement, there was no documentation that these monitoring checks were completed, and the administrator confirmed that no monitoring sheets could be located.
A resident who required moderate assistance for transfers and was cognitively intact reported being told by a speech therapist to urinate in bed if staff were unavailable to help with toileting, rather than attempting to transfer alone. The resident felt degraded by this comment, and the speech therapist confirmed she would give such instructions to prevent unsafe transfers.
A resident with a hip fracture and chronic pain did not receive prescribed pain medications on multiple occasions due to pharmacy and reordering issues, resulting in unmanaged pain. After a change in wound care orders, staff failed to monitor the surgical wound, leading to infection and hospitalization. Staff interviews confirmed lapses in medication administration and wound monitoring.
The facility failed to provide adequate staffing, resulting in delayed care, missed showers, and late meals. Residents experienced long call light wait times, were left in soiled briefs, and received late meal trays. Staff reported being unable to complete care tasks due to high resident acuity and insufficient staffing levels.
A facility failed to adhere to physician's orders for a resident with respiratory failure and asthma, leading to the resident attending an appointment without necessary oxygen support. The resident was later observed receiving oxygen at four liters per minute without a documented order, highlighting a lapse in following prescribed respiratory care protocols.
A resident with a stroke and moderate decision-making impairment was injured when a CNA, frustrated by a reassignment, pushed the resident's shower chair, causing a toe injury. The CNA left the resident alone without a call light and did not report the incident, leading to the resident's mistreatment and injury.
A facility failed to supervise a resident with dysphagia during meals, leading to unsupervised eating. Another resident with dementia and a history of elopement left the facility unsupervised and was missing for nearly 24 hours. Additionally, a resident with a history of falls fell from an elevated bed, resulting in leg fractures, due to inadequate adherence to safety protocols.
A resident reported being served moldy food, prompting an investigation that revealed unsanitary conditions and improper food storage in the facility. The dietary service logs showed inadequate food temperatures, and the unit refrigerator was found with unlabeled sandwiches, a broken shelf, and a sticky, uncleanable wooden shelf. Despite some labeling improvements, the unsanitary conditions persisted.
The facility failed to obtain informed consent for psychotropic medications for four residents. A resident with a pulmonary embolism was prescribed sertraline and lorazepam without consent. Another resident with bipolar disorder received duloxetine without being informed of the risks and benefits. A third resident, readmitted for leg fracture repair, was prescribed haloperidol and Ativan without consent. Lastly, a resident admitted after a stroke was given Lexapro without consent. Staff acknowledged the oversight in obtaining informed consent.
The facility failed to address grievances raised by the Resident Council, leading to a deficiency. Despite a grievance policy requiring immediate action, issues such as poor CNA performance, delayed meals, and mishandling of personal items were not resolved. Frequent changes in administration and unclear grievance handling responsibilities contributed to the problem, with no follow-up or resolutions documented.
The facility failed to ensure the Activities Director was a qualified professional. The Activities Director, promoted in July 2024, lacked the necessary certification, which was confirmed by the Administrator. This placed residents at risk for unmet physical, mental, and psychosocial needs.
The facility failed to ensure that three residents understood the arbitration agreement they signed. Despite being cognitively intact, the residents and their representatives reported a lack of understanding and felt uninformed about the arbitration process. The Admissions Coordinator claimed to explain the process and provide contact information for questions, but the residents' feedback indicated a communication failure.
The facility failed to maintain proper infection control practices, including improper use of PPE, unsanitized medical equipment, and deficiencies in the laundry area. Staff were observed not wearing masks in COVID-19 areas, and a glucometer was not sanitized between uses, risking infection spread. Equipment issues in the laundry room further compromised infection control.
The facility failed to ensure a clean and homelike environment for residents, with issues such as cluttered rooms, unclean bathrooms, unpainted wall patches, and broken window blinds. Staff acknowledged these deficiencies, indicating a lack of effective communication and maintenance reporting.
The facility failed to document and resolve grievances for three residents and one unit, leading to unresolved concerns about missing personal items, rude staff interactions, moldy food, and inadequate incontinence care. Despite residents being cognitively intact and reporting issues, grievances were not properly recorded or communicated, indicating a systemic failure in handling grievances.
The facility experienced significant staffing shortages, resulting in delayed care for residents. Multiple complaints and observations highlighted long call light wait times and unmet care needs, such as incontinence care and meal assistance. A resident with heart disease frequently waited for bowel and bladder care, causing frustration and stress. Staff confirmed the facility was consistently short-staffed, with high turnover and frequent call-offs exacerbating the issue.
The facility did not staff an RN for eight consecutive hours per day for seven days out of 93 reviewed, risking unmet assessment needs. This was identified through staff daily reports from April to September 2024. The administrator, DNS, and regional nurse acknowledged the issue but provided no further information.
The facility failed to post accurate staffing information for six consecutive days, omitting census documentation for various shifts. This placed residents at risk for incomplete staffing information. The Administrator, DNS, and Regional Nurse acknowledged the requirement for staff to document the census for each shift.
A facility failed to ensure a safe system for a resident's self-administration of medication, leading to an adverse reaction. A resident, admitted with heart disease and cognitively intact, was assessed to self-administer medications, but the specific medications were not identified. The resident mistakenly applied Desitin to a skin graft site, worsening its condition. Observations showed unsecured medications in the resident's room, contrary to facility policy. Staff acknowledged the oversight, highlighting a failure in medication management.
A resident with chronic kidney disease expressed a desire to formulate an advance directive with a friend's help. Despite this being noted during a care plan conference, there was no documented follow-up or communication from staff to assist the resident in this process. A social services staff member confirmed the request but lacked documentation of any assistance provided.
A resident with a stroke diagnosis suffered a toe injury when a CNA, frustrated by a reassignment, pushed the resident's shower chair, causing the toe to hit a door. The CNA left the resident alone without a call light and did not report the incident. The facility's investigation lacked interviews with involved parties.
The facility failed to notify the State Long-Term Care Ombudsman of hospitalizations for two residents, one with cancer and another with anxiety and a leg fracture. Both residents were transferred to the hospital without the required notifications, leaving them without access to an advocate. Staff interviews confirmed that medical records staff did not complete the necessary notifications.
The facility failed to provide a bed hold policy to two residents transferred to the hospital, risking their knowledge of the right to return. One resident with cancer and another with anxiety and a leg fracture were not given the policy, and staff were unsure of the procedure. The absence of documentation was confirmed by the facility's administration.
The facility failed to update care plans for three residents, leading to potential unmet needs. A resident with chronic pain had undocumented personal equipment, another with depression and paraplegia lacked specific anxiety interventions and personal care preferences, and a third resident's care plan did not include interventions for psychotropic medications. Staff acknowledged these oversights.
Two residents in the facility experienced a lack of meaningful activities, leading to potential isolation. One resident with dementia and depression was often bored and unable to go outside due to the discontinuation of their electric wheelchair. Another resident with depression and anxiety reported that staff did not inquire about their interest in activities like crocheting. Staffing challenges in the activities department and the absence of activities staff at care conferences contributed to these deficiencies.
A resident with depression and paraplegia required hearing services, specifically ear cleaning, as identified in a care plan conference. Despite this, staff acknowledged ongoing hearing issues and ear wax build-up, which were not addressed due to the Unit Manager's failure to obtain necessary physician orders.
A resident at risk for pressure ulcers developed a Stage 3 ulcer that was not assessed or treated in a timely manner. Despite being reported by a CNA, the ulcer was not comprehensively assessed until three days later, and treatment was delayed. The LPN did not stage the ulcer, citing scope of practice limitations, and the presence of an RN in the facility did not lead to timely intervention.
The facility failed to provide adequate respiratory care for three residents. A resident with chronic pain had an unused, dusty suction machine in their room, contrary to physician orders. Another resident with a pulmonary embolism did not receive documented oxygen therapy, and staff were unclear about the orders. A third resident with respiratory failure had a nebulizer improperly stored and without cleaning instructions. These deficiencies indicate a lack of adherence to physician orders and standards of practice.
A resident with a leg fracture and pain from orthopedic devices did not receive PRN pain medication as ordered, despite frequent requests. The resident, cognitively intact, reported activating the call light for pain relief, but staff did not respond promptly due to low staffing and high workload. The facility acknowledged the expectation to administer pain medications as ordered.
A facility failed to provide appropriate post-dialysis care for a resident with end-stage renal disease. The resident's care plan required monitoring for infection, bleeding, and symptoms of kidney malfunction, as well as checking the thrill and bruit of the fistula. However, these checks were not consistently documented, and the order for checking the thrill and bruit was discontinued. Staff acknowledged missing documentation and poor communication with the dialysis center.
A facility failed to administer a prescribed fentanyl patch to a resident with post-surgical leg fractures due to a lack of a valid prescription. The pharmacy did not receive the necessary prescription, and staff did not follow up adequately to resolve the issue, despite the medication being available in the automated dispensing system.
The facility failed to monitor two residents on psychotropic medications, risking unnecessary medication use. One resident with bipolar disorder was not monitored for side effects of duloxetine, while another on hospice care received Ativan PRN without a care plan or non-pharmacological interventions. Staff acknowledged the lack of documentation and monitoring systems.
The facility failed to notify the physician and family members of three residents regarding refusals and changes in condition. A resident refused a prescribed lidocaine patch multiple times without physician notification. Another resident's family was not informed when the resident was sent to the hospital for catheter reinsertion. A third resident experienced a significant drop in oxygen levels, yet the physician was not notified.
A resident with dementia, stroke, alcohol abuse, and seizures eloped from the facility, and the incident was not reported to the State Agency until three days later. Staff failed to inform the administration about the elopement in a timely manner.
A CMA in the facility falsified documentation by guessing a resident's blood pressure instead of measuring it before administering Baclofen, a muscle relaxant. The medication was to be withheld if the systolic blood pressure was below 100, but the CMA documented a reading of 100/68 and administered the drug, despite the actual reading being 89/65. This action was confirmed by an LPN after a CNA reported the discrepancy.
The facility failed to provide adequate grooming and bathing care for three residents, leading to unmet needs. A resident with chronic pain received fewer showers than scheduled, while another with depression and paraplegia was not consistently assisted with bathing and shaving. A third resident, post-stroke, experienced inadequate bathing care due to staffing issues and lack of follow-up on refusals.
A facility failed to provide adequate care for residents with bowel, bladder, and catheter needs. One resident experienced significant delays in receiving bowel and bladder care, leading to frustration and stress. Another resident with a suprapubic catheter was not properly monitored, resulting in the catheter slipping out during routine care. A third resident with an allergy to aloe suffered from inappropriate incontinent care due to staff using the wrong wipes, causing skin irritation. These deficiencies highlight issues with staffing, communication, and adherence to care plans.
A facility failed to arrange specialized physician appointments for a resident with chronic pain, as identified during a survey following a public complaint. The resident was supposed to receive referrals to neurology and cardiology and a bilateral ultrasound-guided glenohumeral injection, as per a physician order. However, a staff member from Social Services acknowledged that these appointments were not scheduled.
A significant medication error occurred when a CMA failed to obtain a resident's blood pressure before administering Baclofen, a muscle relaxant. The resident's blood pressure was below the threshold for medication administration, but the CMA guessed the reading based on the morning measurement, leading to the medication being given inappropriately. An LPN was alerted to the error by a CNA, prompting an investigation.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to provide RN coverage for eight consecutive hours per day, seven days per week, as required, on 21 of 78 reviewed days between August and November 2025. Review of the Direct Care Staff Daily Reports for 8/2025, 9/2025, 10/2025, and 11/2025 showed that on multiple specific dates in each of those months there was no RN documented as being on duty for the required eight-hour period. Staff interviews revealed that staff were only instructed to begin reporting the RN manager on the Direct Care Staff Daily Report starting 1/13/25, and the Administrator stated that staff were expected to call off work two hours before their shift to allow time to find coverage. Surveyors requested payroll documentation to verify RN work on the identified dates, but no additional documentation was provided, and the deficiency was cited as placing residents at risk for unmet assessment needs. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency was based on staffing records, staff interviews, and the absence of corroborating payroll documentation for RN coverage on the listed dates.
Failure to Process and Track Resident Grievance for Missing Personal Property
Penalty
Summary
The deficiency involves the facility’s failure to promptly process and resolve a resident grievance related to missing personal property, as required by its Resident Rights Grievances Policy and Procedure. The policy, revised in 3/2023, assigns the grievance officer responsibility for overseeing the grievance process, receiving and tracking grievances through conclusion, leading investigations, maintaining confidentiality, and issuing written grievance decisions. It also requires staff to immediately report any grievance alleging misappropriation of resident property to the grievance officer, with reports to be made available within seven business days and a summary report of the investigation available to the resident. Despite these requirements, the facility’s grievance list for 7/2025 and 8/2025 contained no grievances for the resident in question. The resident, admitted in 2/2025 with a diagnosis including depression and documented as cognitively intact with a BIMS score of 15 on an 8/31/25 MDS, reported missing jewelry, an oximeter, and art supplies in 8/2025. The resident stated these missing items were reported both to staff and during a resident council meeting, and the 8/26/25 Resident Council minutes reflected that residents reported missing items from their rooms, with this resident in attendance. A CNA reported that the resident told her in 8/2025 about missing earrings and an oximeter and that she reported this to the charge nurse, but did not assist with another grievance form because the resident had completed one the day before. The Director of Social Services and Recreation stated he did not remember any grievances for this resident regarding missing items and that no grievances were found for the resident for 8/2025, suggesting the grievance may have been submitted but lost due to confusion among multiple staff. The Administrator stated he would have expected staff to complete a grievance and have it resolved within five days, which did not occur in this case.
Failure to Report Resident Elopement as a Facility-Reported Incident
Penalty
Summary
The facility failed to report an incident of potential neglect related to an elopement involving Resident 28 to the State Survey Agency. Resident 28, admitted in February 2025 with diagnoses including anxiety and a cognitive communication deficit affecting expressive and receptive language, was found on 3/6/25 at approximately 4:30 PM about a block away from the facility next to a busy street. An Elopement Investigation Report dated 3/7/25 documented that the root cause of the incident was the resident’s confusion and a non-functioning wander guard (electronic monitoring device). Despite this documented elopement event and investigation, there was no evidence that the incident was reported to the State Survey Agency. During interviews, the former Administrator (Staff 40) stated she could not remember if the elopement was reported and indicated she would not report an elopement because it was no longer listed on the Facility Reported Incident (FRI) form. The current Administrator (Staff 1) stated that, to his knowledge, no FRI was completed for the resident’s elopement, and the Regional RN (Staff 22) stated that if there was an alleged violation, it would be expected that an FRI be submitted for an elopement.
Failure to Monitor Wander Guard and Document Safety Checks for Wandering Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and ensure proper monitoring for a resident with severe cognitive impairment and a history of wandering. The resident was admitted with anxiety and a cognitive communication deficit, and an admission MDS documented a BIMs score of three, indicating severe cognitive impairment. A care plan dated 3/4/25 identified episodes of wandering and ordered a Wander Guard to be placed on the resident’s wheelchair, with interventions including checking the Wander Guard placement on every shift and using diversions such as activities, food, conversation, television, and books. A TAR initiated in 3/2025 instructed staff to check the Wander Guard placement on the left area of the wheelchair every shift. However, there was no documented evidence in the clinical record that staff were checking the Wander Guard to ensure it was functioning properly. On 3/6/25, an elopement occurred in which the resident was found approximately one block away from the facility next to a busy street. An Elopement Investigation Report identified the root cause as the resident’s confusion and a non-functioning Wander Guard. A former physical therapist assistant reported finding the resident very confused and in a precarious position near the busy street and stated that a CNA assisted in returning the resident to the facility. The CNA reported that the resident did not have a Wander Guard on the wheelchair at that time. Although the resident was placed on 15‑minute checks with a monitoring sign‑up sheet created, there was no documented evidence in the clinical record that staff conducted these 15‑minute checks following the elopement. The administrator confirmed that no 15‑minute monitoring sheets could be located and stated that it would be expected for staff to check Wander Guard placement and functionality.
Resident Instructed to Urinate in Bed Rather Than Transfer Independently
Penalty
Summary
A resident with a history of hip fracture and fibromyalgia, who was cognitively intact and required moderate staff assistance for transfers, reported being told by a speech therapist to urinate in bed if staff were not available to assist with toileting, rather than attempting to transfer independently. The resident described this comment as mortifying and degrading. The speech therapist stated she did not recall the specific resident but acknowledged that she instructs residents to follow safety recommendations and, if aware of unsafe transfer attempts, would advise urinating in bed rather than risking injury by transferring alone. The interim Director of Nursing Services did not recall the incident or the resident but stated that staff are expected to treat all residents with dignity and respect.
Failure to Administer Medications and Monitor Wound Care per Orders
Penalty
Summary
The facility failed to administer medications according to provider orders and did not properly monitor a surgical wound for a resident admitted with a hip fracture and fibromyalgia. Medication administration records showed that Tramadol was not given on several occasions due to the facility not obtaining the medication from the pharmacy, and Oxycodone supplies also ran out, requiring emergency orders. Progress notes and interviews confirmed that the resident experienced significant pain on days when medications were missed, and both the resident and a family member reported multiple instances of being without pain medication. Staff interviews revealed lapses in medication reordering and administration, with admissions that medications were sometimes missed or late due to ordering issues. Additionally, after a change in wound care orders to a honeycomb dressing, there were no instructions for ongoing wound monitoring, and staff did not implement further wound observations or treatments. The resident subsequently developed signs of infection, including fever, chills, and wound redness, and was sent to the emergency department for treatment. Staff interviews indicated that wound care monitoring was expected but not consistently performed, and multiple attempts to reach the wound care nurse were unsuccessful.
Inadequate Staffing Leads to Delayed Care and Missed Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in missed or delayed care, missed or late meals, and increased safety risks. Observations revealed call light wait times of up to 40 minutes, and grievances highlighted instances where residents were left in soiled briefs for extended periods, missed showers, and received late meal trays. The facility's staffing records showed consistent shortages of Certified Nursing Assistants (CNAs) across multiple months, contributing to these deficiencies. Residents and their families reported numerous issues related to inadequate staffing. Residents frequently experienced long wait times for call lights to be answered, leading to missed incontinence care and delayed meals. Some residents were found soaked in urine, and others missed showers or had to wait for assistance with meals. Family members also observed these issues, with some taking it upon themselves to provide basic care, such as changing soiled briefs and emptying urinals, due to the lack of staff response. Staff members corroborated these accounts, describing the staffing situation as inadequate for the high acuity level of residents. They reported being unable to complete care tasks, such as showers and personal hygiene, and having to perform two-person transfers alone. The facility's staffing coordinator admitted to not staffing based on residents' acuity or needs, further exacerbating the problem. This systemic issue led to a failure in providing timely and adequate care to residents, as evidenced by the numerous grievances and staff testimonies.
Failure to Follow Oxygen Administration Orders
Penalty
Summary
The facility failed to follow physician's orders related to oxygen administration for a resident diagnosed with respiratory failure with hypoxia and asthma. The resident was initially admitted with an order for continuous oxygen at 2 liters per minute via nasal cannula, which was discontinued upon their transfer to the hospital. Upon readmission, the resident did not have an order for oxygen. On a specific date, a staff member confirmed that the resident attended an appointment without an oxygen tank, resulting in a pulse oxygen reading of 64%. Observations on subsequent dates revealed the resident using a nasal cannula with an oxygen concentrator set at four liters per minute, despite no documented order for this level of oxygen. Staff confirmed the resident was on continuous oxygen without an order, and the Director of Nursing Services was informed of the situation.
Resident Injured Due to Staff's Physical Abuse and Neglect
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by staff, resulting in physical injury. The incident involved a resident who was admitted with a stroke and had moderate decision-making impairment due to aphasia. The resident communicated using yes or no questions and gestures. On the day of the incident, a CNA was reassigned from her usual duties to provide direct care to residents, which led to her becoming angry. In her frustration, she pushed the resident's shower chair hard out of the shower room, causing the resident's toe to hit the door, resulting in a lifted toenail and bleeding. The CNA left the resident alone in the room without a call light and did not report the incident to another CNA. Multiple staff members, including another CNA and unit managers, confirmed the sequence of events, noting that the CNA left the resident in a vulnerable state, with only a towel on and the water running. The DNS acknowledged that the CNA did not complete a proper hand-off or report before leaving the floor, which contributed to the resident's mistreatment and injury.
Inadequate Supervision and Safety Protocols in LTC Facility
Penalty
Summary
The facility failed to provide adequate supervision for Resident 55, who was diagnosed with dysphagia and dementia. Despite the care plan requiring supervision during meals, Resident 55 was repeatedly observed eating alone in the dining room and in their room without staff presence. This lack of supervision posed a significant risk to the resident's safety, particularly given their difficulty swallowing and cognitive impairments. Resident 93, who had a history of dementia, stroke, alcohol abuse, and seizures, was allowed to leave the facility without proper supervision or signing out, as required by the facility's elopement prevention guidelines. The resident was missing for nearly 24 hours, during which time they were found by law enforcement five miles away from the facility with a non-functioning power wheelchair. Staff interviews revealed a lack of concern and adherence to protocol, as the resident was known to leave the facility unsupervised, despite being cognitively and physically unable to do so safely. Resident 164, who had a history of falls and cognitive impairment, fell from an elevated bed, resulting in fractures to both legs. The resident's care plan included interventions to prevent falls, but the bed was consistently kept at a high position, contrary to standard care practices. Staff failed to ensure the bed was in a low position or to provide mats on the floor, contributing to the resident's fall. The incident highlighted a lack of adherence to safety protocols and inadequate risk assessment for the resident's known fall risks.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to serve food at appropriate temperatures and maintain sanitary conditions, which placed residents at risk for foodborne illnesses. One resident, who was cognitively intact and had a diagnosis of heart disease, reported being served moldy food. The former administrator confirmed that the resident called the police regarding the moldy food, and although the facility discarded perishable snacks, there was no verification of the food's condition. A Licensed Practical Nurse (LPN) saw photos of the food, which showed a sandwich with green mold and a fruit cup with white bumps, indicating the onset of mold. Additionally, the facility's dietary service logs recorded inadequate holding temperatures for chicken, poultry, and meatloaf, with no system in place to verify final cooking temperatures. The unit refrigerator was found in an unsanitary condition, with sandwiches lacking expiration labels, a broken shelf, and a sticky, uncleanable wooden shelf. The Infection Prevention Nurse confirmed the unsanitary conditions and the need for a cleanable surface shelf. Despite the addition of date labels on sandwiches, the overall condition of the refrigerator and surrounding area remained unchanged over five days.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to provide informed consent for the use of psychotropic medications to four out of five sampled residents. Resident 55, admitted with a pulmonary embolism, was prescribed sertraline and lorazepam without documentation of informed consent. Staff acknowledged a system issue related to providing risk and benefits information. Resident 87, diagnosed with bipolar disorder, received duloxetine without being informed of the risks and benefits, as confirmed by a Unit Manager. Resident 164, readmitted for surgical repair of leg fractures, was prescribed haloperidol and Ativan without obtaining consent, as social services staff were not present to obtain it. Resident 165, admitted after a stroke, was administered Lexapro without consent, with social services staff acknowledging the oversight. The lack of informed consent for these medications placed residents and their responsible parties at risk for lack of informed consent.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to provide a response to grievances raised by the Resident Council, which was identified as a deficiency. The grievance policy, revised in March 2023, required the grievance officer, typically the administrator, to take immediate action to prevent further potential violations of any resident rights while a grievance was investigated. However, the facility did not adhere to this policy. The Resident Council minutes from July and August 2024 documented several unresolved issues, including poor CNA performance, delayed meals, and mishandling of personal items. During a meeting in September 2024, residents expressed that their grievances were not addressed, and they received no follow-up, which affected their psychosocial well-being. The facility experienced frequent changes in administration, with three different administrators in the past year, leading to inconsistent communication and a lack of clarity regarding grievance handling responsibilities. Staff 7, the Activities Director, noted that grievances were given to department heads who were unaware of the proper procedures, resulting in a breakdown in the grievance process. The online grievance log lacked a follow-up section and did not specify who was responsible for addressing concerns. Staff 1 confirmed that there were no resolutions to the grievances, indicating a systemic failure in the facility's grievance handling process.
Unqualified Activities Director
Penalty
Summary
The facility failed to provide a qualified professional to direct the activities program, which was identified during an interview and record review. Staff 7, who was responsible for directing the activities program, including organizing the Resident Council, had been working in the activities department since May 2023 and was promoted to the Director position in July 2024. However, Staff 7 acknowledged that she did not have the required activities certification. This was confirmed by Staff 1, the Administrator, who admitted that the certification for Staff 7 was not completed as required. This deficiency placed residents at risk for unmet physical, mental, and psychosocial needs.
Failure to Ensure Residents Understand Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents understood the meaning of an arbitration agreement, which involves resolving disputes with a neutral party rather than in court. This deficiency was identified for three residents who were cognitively intact at the time of signing the agreement. Resident 19, admitted with a fracture of the left femur and chronic kidney disease, stated they knew what arbitration meant but did not remember signing the agreement. Resident 163, admitted with kidney and respiratory failure, remembered signing the agreement but their spouse had questions about the process and felt pressured to sign. Resident 262, admitted with respiratory failure and gout, did not remember signing the agreement and stated that arbitration was not explained during admission. Staff 59, the Admissions Coordinator, stated that she informed all new admissions of their right to decline or agree to arbitration and that they had 30 days to change their mind. She claimed to explain the definition and process of arbitration and offered a copy of the agreement to all admissions, providing her business card for any questions. Despite these claims, the residents and their representatives reported a lack of understanding and felt uninformed about the arbitration process, indicating a failure in communication and ensuring informed consent.
Infection Control Deficiencies in PPE Use and Equipment Handling
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices across multiple areas, including the use of personal protective equipment (PPE) and the handling of medical equipment. Observations revealed that staff members were not consistently wearing masks, particularly in areas with active COVID-19 cases. Additionally, PPE storage bins outside COVID-19 positive rooms were missing supplies, and staff were not wearing proper eye protection in these areas. The breakfast cart was observed with an uncovered tray, which was delivered to a resident's room, contrary to infection control protocols. Furthermore, the community use CBG glucometer was not sanitized between uses, posing a risk of bloodborne illness transmission. The laundry area also exhibited significant deficiencies, including a fan blowing from the dirty to the clean side, visible dirt on the fan, and inadequate air circulation. Equipment issues were noted, such as a leaking washing machine, a broken dryer heating element, and a washing machine with a broken door. These issues were acknowledged by staff, who indicated that repairs had been attempted multiple times without permanent resolution. Resident 20, who was cognitively intact and had a history of diabetes and infection, was directly affected by the improper sanitization of the CBG glucometer, as observed during a blood sugar check.
Deficiencies in Maintaining a Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for its residents, as evidenced by multiple deficiencies observed in the rooms of five residents. Resident 2's room was cluttered with various items, including an arctic air conditioner covered in thick dust, which had not been cleaned for three years despite the resident's requests for assistance. Resident 62's bathroom was found to be unclean, with urine and dark brown debris around the toilet bowl and yellow-colored debris on the floor, despite housekeeping efforts. Staff acknowledged these conditions, confirming the lack of a homelike environment. Additional deficiencies were noted in the rooms of Residents 98, 71, and 162. Resident 98's room had an unpainted wall patch that had been present since their move-in, and Resident 71 confirmed the patch was there during their stay. Resident 162 reported a broken window blind control wand, which was not recorded in the maintenance log, preventing the adjustment of blinds to let sunlight into the room. Maintenance staff confirmed the missing wand and acknowledged the dependency on nursing staff to report such issues, highlighting a communication gap in addressing maintenance concerns.
Failure to Document and Resolve Resident Grievances
Penalty
Summary
The facility failed to honor residents' rights to voice grievances without discrimination or reprisal, as evidenced by the lack of documentation and resolution of grievances for three residents and one unit. Resident 63, who was cognitively intact, reported a missing ring, but there was no grievance documentation or progress notes regarding the incident, despite the administrator's acknowledgment of the issue. Resident 98, also cognitively intact, reported rude treatment by staff and delays in care, but no grievance form was completed, and the administrator was unaware of the concern. Additionally, Resident 162, who was cognitively intact, reported moldy food and called the police, but there was no grievance form related to the issue, and the current administrator was not aware of the incident. Furthermore, a public complaint was received about untimely incontinence care and an unplugged call light, but only one grievance was documented for the month. Witness 4 reported multiple residents with unmet care needs, including missing blankets and skin breakdown due to lack of incontinence care, but these concerns were not documented in the grievance log. Staff 33 and the unit managers acknowledged the issues, but the grievances were not properly recorded or communicated to the administration, indicating a systemic failure in the facility's grievance handling process.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of residents, as evidenced by multiple complaints and observations of long call light wait times and unmet care needs. Residents reported waiting excessively for assistance, with some experiencing incontinence due to delays. Staff interviews confirmed that the facility was consistently short-staffed, leading to delays in care and incomplete tasks such as showers and meal assistance. Resident 24, who was cognitively intact and admitted with a diagnosis of heart disease, frequently experienced delays in receiving bowel and bladder care. On one occasion, the resident activated the call light for assistance, but staff did not respond promptly, resulting in the resident waiting with a soiled brief. This delay caused significant frustration and emotional stress for the resident, who also reported that staff did not wake them for meals, leading to cold food being left uneaten. Staff members expressed frustration with the staffing challenges, noting that they were unable to provide the necessary care to residents. The facility experienced high staff turnover and frequent call-offs, exacerbating the staffing shortages. Observations and interviews revealed that call light wait times often exceeded 30 minutes, with some instances reaching up to 99 minutes. The facility also faced challenges during outbreaks of norovirus and COVID-19, which further strained staffing resources.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to staff a registered nurse (RN) for eight consecutive hours per day, seven days a week, for seven out of 93 days reviewed. This deficiency was identified through a review of the Direct Care Staff Daily Reports covering specific periods from April to September 2024. The reports revealed that on seven days, there was no RN coverage for eight consecutive hours on any shift within a 24-hour period. This lack of consistent RN coverage placed residents at risk for unmet assessment needs. During interviews on September 13, 2024, the facility's administrator, director of nursing services (DNS), and regional nurse acknowledged the issue but did not provide additional information regarding the required RN coverage.
Failure to Document Census in Staffing Reports
Penalty
Summary
The facility failed to post accurate and complete staffing information for six consecutive days, which placed residents at risk for incomplete and inaccurate staffing information. On multiple occasions, the Direct Care Staff Daily Report lacked documentation of the census for various shifts. Specifically, on September 8th, no census was documented for the day and evening shifts, and the night shift posting was incomplete. Similar omissions occurred on September 9th, 10th, 11th, 12th, and 13th, with the day shift census missing on each of these days. During an interview on September 13th, the Administrator, Director of Nursing Services, and Regional Nurse acknowledged that staff should document the census for each shift on the report.
Failure in Safe Medication Self-Administration System
Penalty
Summary
The facility failed to ensure a safe system for a resident's self-administration of medication, which placed residents at risk for adverse medication reactions. Resident 44, who was admitted in 2021 with a diagnosis of heart disease and was cognitively intact, was assessed on a Self-Administration of Medication form to be capable of self-administering medications. However, the form did not specify which medications the resident could self-administer. The resident's care plan indicated that they self-administered over-the-counter supplements kept at their bedside, but it also failed to identify specific medications for self-administration. An incident occurred where Resident 44 mistakenly applied Desitin to an old skin graft donor site, which worsened the condition of the site. Observations revealed that the resident's room contained multiple bottles of supplements, creams, and liquid disinfectants, including a tube of Desitin, which were not secured as required. Staff acknowledged that medications were supposed to be locked in a secure area and that the resident had orders for only two supplements to be kept at the bedside. This oversight in medication management and storage led to the resident's adverse reaction and highlighted the facility's failure to maintain a safe self-administration system.
Failure to Assist Resident with Advance Directive
Penalty
Summary
The facility failed to assist a resident with formulating an advance directive, which is a deficiency in honoring residents' rights to make end-of-life choices. The resident, admitted in 2022 with chronic kidney disease, was cognitively impaired but able to express needs and desired to create an advance directive with the help of a friend. During an IDT Care Plan Conference, this wish was noted, but from the period of late July to early September, there was no documentation of follow-up or communication with the resident or their friend regarding the advance directive. A staff member from Social Services acknowledged the resident's request but could not provide any documentation of assistance being offered or completed.
Failure to Investigate Resident Injury
Penalty
Summary
The facility failed to thoroughly investigate an injury involving a resident who was admitted with a diagnosis of stroke. On the day of the incident, a CNA was responsible for showering the resident and accidentally bumped the resident's foot against the wall while exiting the shower room. The CNA left the facility before the end of her shift, leaving the resident sitting in the shower chair. Another CNA later found the resident's toe bleeding, with no prior report or communication about the incident. The facility's investigation, conducted by a Unit Manager-LPN, did not include interviews with the resident, other CNAs, or nurses involved. A staff member reported that the CNA became angry due to a reassignment and pushed the resident's shower chair hard, causing the resident's toe to hit the door, resulting in a lifted toenail and significant bleeding. The CNA left the resident alone in the room without a call light and did not inform another CNA of her departure.
Failure to Notify Ombudsman of Resident Hospitalizations
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman regarding the hospitalization of two residents, which is a requirement to ensure residents have access to an advocate who can inform them of their options and rights. Resident 95, who was admitted with a diagnosis of cancer, requested to be sent to the hospital for shortness of breath. Emergency services were called, and the resident was transferred to the hospital. However, there was no documentation in the resident's clinical record indicating that the State Long-Term Care Ombudsman was notified of this transfer. Similarly, Resident 262, admitted with diagnoses including anxiety and a leg fracture, was transferred to the hospital for a disimpaction procedure after experiencing severe pain. Despite being cognitively intact, as indicated by a BIMS score of 15, there was no documentation of a transfer notice with appeal rights being provided to the resident or notification to the Ombudsman. Staff interviews revealed that the medical records staff, who were responsible for sending discharge information to the Ombudsman, did not complete these notifications.
Failure to Provide Bed Hold Policy to Hospitalized Residents
Penalty
Summary
The facility failed to provide a bed hold policy to two residents who were transferred to the hospital, which is a requirement to ensure residents are informed of their right to return to the facility. Resident 95, who was admitted with a diagnosis of cancer, was transferred to the hospital for shortness of breath. There was no documentation in Resident 95's clinical record indicating that a bed hold policy was provided at the time of discharge. Staff members, including those from social services and admissions, were unsure of who was responsible for providing the bed hold policy, and it was confirmed that the policy was not present in the resident's record. Similarly, Resident 262, admitted with anxiety and a leg fracture, was transferred to the hospital for a disimpaction procedure. The resident's clinical records lacked documentation of a bed hold policy being provided in writing at the time of transfer. The resident, who was cognitively intact, stated they were unaware of the bed hold policy. The facility's administrator and director of nursing services confirmed that no bed hold notice was given to Resident 262 upon transfer to the hospital.
Failure to Revise Care Plans for Personal Equipment and Medications
Penalty
Summary
The facility failed to revise care plans for three residents, leading to potential unmet needs. Resident 2, admitted in May 2016 with chronic pain, had a mini arctic air conditioner and a suction machine in their room, but these were not documented in the care plan as of July 2024. This oversight was acknowledged by the Unit Manager-LPN during an observation in September 2024. Resident 86, admitted in March 2024 with depression and paraplegia, had a care plan revised in June 2024 that lacked specific interventions for anxiety and personal preferences for dressing and shaving. Staff noted the resident required encouragement to accept care due to anxiety, and the resident expressed a preference for being clean-shaven and choosing clothes when leaving the facility. The absence of these details in the care plan was confirmed by the Social Services staff. Additionally, Resident 165, readmitted in August 2024 post-surgery, had a care plan from 2022 that did not include interventions for the use of haloperidol and Ativan, nor monitoring for adverse reactions or triggers for anxiety. The LPN Resident Care Manager acknowledged that the care plan was not updated.
Failure to Provide Meaningful Activities for Residents
Penalty
Summary
The facility failed to provide meaningful activities for two residents, leading to a lack of social interaction and potential isolation. Resident 14, who has dementia and depression, expressed a desire to engage in favorite activities and go outside. However, observations revealed that the resident often sat in the hallway with nothing to do and was bored. The resident's care plan was not updated to reflect the discontinuation of their electric wheelchair, which limited their ability to go outside independently. Additionally, the activities staff did not attend care conferences, resulting in a lack of support for the resident's activity needs. Resident 54, diagnosed with depression and anxiety, also experienced a lack of engagement in activities. Despite expressing interest in activities such as crocheting, the resident reported that staff did not inquire about their interests. The activities department faced staffing challenges, which contributed to incomplete assessments and a failure to capture important information about residents' preferences. The absence of activities staff at care conferences further hindered the facility's ability to meet the residents' needs.
Failure to Provide Hearing Services
Penalty
Summary
The facility failed to follow through on necessary hearing services for a resident, leading to a deficiency in maintaining adequate hearing. The resident, admitted in March 2024 with diagnoses including depression and paraplegia, was identified during a care plan conference in May 2024 as requiring hearing services, specifically ear cleaning. Despite this, a quarterly assessment at the end of May indicated the resident had no hearing aids and adequate hearing. However, by September, staff acknowledged the resident had hearing issues and ongoing ear wax build-up, which was supposed to be addressed through physician orders. The Unit Manager confirmed that she neglected to obtain the necessary physician orders for ear wax removal, resulting in a lack of follow-through on the required services.
Delayed Assessment and Treatment of Pressure Ulcer
Penalty
Summary
The facility failed to ensure timely assessment and treatment of a pressure ulcer for a resident who was admitted with no pressure ulcers but was at risk due to incontinence and required assistance for repositioning. On a specific date, a CNA reported an open area on the resident's coccyx, but no comprehensive assessment was conducted until three days later. The wound was identified as a Stage 3 pressure ulcer with significant slough, and it was determined to be facility-acquired. Treatment was not documented as completed until four days after the initial report. The delay in assessment and treatment was partly due to the LPN's understanding that staging a pressure ulcer was outside their scope of practice, and the absence of a comprehensive assessment by an RN, despite one being present in the building. The facility's staff acknowledged the delay in staging and measuring the ulcer, which should have been done when the pressure ulcer was first identified.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care and services according to physician orders and standards of practice for three residents. Resident 2, admitted with chronic pain, had a suction machine in their room that was covered in dust and had not been used for years, despite a physician order to check and replace the canister weekly. The unit manager acknowledged the oversight and confirmed the machine should have been removed as it was not in use. Resident 55, admitted with a pulmonary embolism, had orders for oxygen therapy to maintain oxygen saturation levels above 90 percent. However, from the beginning of September, there was no documentation of oxygen administration, and observations confirmed the resident was not receiving oxygen. The facility staff were unsure if the orders were PRN, and the hospice medication list provided was not a signed physician's order. Resident 87, with respiratory failure and congestive heart failure, was to receive inhalation medication but had their nebulizer improperly stored and without clear instructions for cleaning and maintenance. The unit manager acknowledged the need for proper cleaning and storage instructions.
Failure to Administer PRN Pain Medication as Ordered
Penalty
Summary
The facility failed to provide pain medications as ordered for a resident admitted with a leg fracture and pain due to internal orthopedic prosthetic devices. The resident, who was cognitively intact with a BIMS score of 15, experienced frequent pain affecting sleep quality and daily activities, with pain levels reaching up to 10 on a scale of zero to 10. The medication administration record (MAR) for September instructed staff to administer oxycodone 5 mg every four hours PRN for moderate pain, with specific dosages based on pain levels. On September 7, the resident was administered 10 mg of oxycodone at 1:07 AM, 5:14 AM, and 12:11 PM for pain levels of eight and 10. However, the resident reported activating the call light at 9:15 AM on September 7 to request PRN pain medication, but no staff responded until 12:00 PM when lunch was delivered. Staff interviews revealed that the resident was consistent in requesting PRN pain medications, but due to low staffing levels and high workload, the medication was not administered as needed. Staff 46, who was responsible for administering the medication, stated that she might not have been informed of the resident's request and was assigned to both units, which may have prevented her from administering the medication. The facility's administration confirmed the expectation to provide pain medications as ordered by the physician and to follow through with PRN requests.
Failure to Provide Proper Post-Dialysis Care
Penalty
Summary
The facility failed to provide appropriate post-dialysis care and services for a resident with end-stage renal disease who was dependent on renal dialysis. The resident, who was cognitively intact, reported that staff did not check her/his fistula or vitals upon return from dialysis sessions. The resident's care plan required monitoring for infection at the fistula site, bleeding, and symptoms of kidney malfunction, as well as checking the thrill and bruit of the fistula. However, the Medication Administration Records (MARs) and Treatment Administration Records (TARs) from June to September 2024 did not include orders for these necessary checks, and the order to check the thrill and bruit was discontinued in June 2024. The resident had 45 opportunities to attend dialysis sessions between June and September 2024, but the facility completed pre-dialysis paperwork only 35 times and post-dialysis paperwork just four times. Staff interviews revealed that the pre-dialysis forms were sometimes lost, and there was poor communication with the dialysis center. The Unit Manager acknowledged the missing documentation and the lack of an order for checking the thrill and bruit, indicating a failure to adhere to the care plan and ensure proper post-dialysis monitoring.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to obtain a resident's medication, specifically a fentanyl patch, for a resident who was readmitted with a diagnosis of post-surgical repair of leg fractures. The medication administration record (MAR) indicated that the fentanyl patch was to be applied starting on 9/9/24, but it was not applied. A pharmacy technician stated that the pharmacy did not receive a valid prescription from the provider and had requested a new prescription on 9/9/24, which had not yet been received. Staff members, including an LPN and the LPN Staffing Coordinator, indicated that if a medication was unavailable, the nurse should follow up with the pharmacy and check the automated medication dispensing system. It was noted that a fentanyl patch was available in the dispensing system, but staff did not follow up with the pharmacy to obtain authorization to remove it, as they were unaware of the lack of a valid prescription.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to adequately monitor two residents who were prescribed psychotropic medications, leading to a risk of unnecessary medication use. Resident 87, admitted with bipolar disorder, was receiving duloxetine for depression without proper monitoring for adverse reactions or behaviors. Despite the care plan indicating the need for monitoring, there was no system in place to track the effectiveness or side effects of the antidepressant. Staff acknowledged the lack of documentation and monitoring for the resident's medication use. Resident 164, who was on hospice care, was prescribed Ativan PRN for anxiety without a developed care plan for its use or documentation of non-pharmacological interventions prior to administration. Additionally, there was no monitoring for side effects of the antianxiety and antipsychotic medications prescribed. Staff admitted to the absence of a care plan and monitoring system for these medications, indicating a gap in the facility's medication management practices.
Failure to Notify Physician and Family of Resident Condition Changes
Penalty
Summary
The facility failed to notify the physician or resident representative regarding refusals and changes in condition for three residents. Resident 55, admitted with chest pain, refused a prescribed lidocaine patch for pain relief nine times over nine days, yet there was no documentation that the physician was informed of these refusals. The facility administrator confirmed that the physician was not notified during this period. Resident 86, admitted with a UTI and paraplegia, had a catheter dislodged and was sent to the hospital for reinsertion. The family was not notified immediately, as the staff chose to wait until later in the morning. The unit manager acknowledged that the family should have been informed immediately. Resident 165, admitted with pneumonia, experienced a significant drop in oxygen levels after removing their oxygen device multiple times during the night. Despite the critical drop in oxygen levels, the physician was not notified, as confirmed by the DNS and the staff involved.
Failure to Timely Report Resident Elopement
Penalty
Summary
The facility failed to report an allegation of elopement in a timely manner to the State Survey Agency for one of the sampled residents. The resident, who was admitted with diagnoses including dementia, stroke, alcohol abuse, and seizures, left the facility without authorization. The incident occurred on September 6, 2024, but was not reported to the State Agency until September 9, 2024. Interviews with the facility's Administrator, Director of Nursing Services, and Regional Nurse revealed that the staff did not inform the facility administration about the elopement until September 9, 2024, three days after the incident occurred.
Falsification of Documentation by CMA
Penalty
Summary
The facility failed to ensure that staff did not falsify documentation, which placed residents at risk for adverse medication reactions. Specifically, a Certified Medication Aide (CMA), identified as Staff 20, did not obtain the required vital signs before administering medication to a resident. The resident, who was admitted with a diagnosis of paraplegia and was cognitively intact, was prescribed Baclofen, a muscle relaxant, to be administered three times a day. The medication was to be withheld if the resident's systolic blood pressure was less than 100. On the day of the incident, Staff 20 documented a blood pressure reading of 100/68 and administered the medication, despite the actual blood pressure being 89/65. An investigation revealed that Staff 20 did not take the resident's blood pressure at the time of medication administration but instead guessed the reading based on the morning's measurement. This action was confirmed when Staff 19, an LPN, was informed by a CNA of the resident's actual blood pressure and questioned Staff 20 about the discrepancy. Staff 20 admitted to fabricating the blood pressure reading and entering it into the Medication Administration Record (MAR). This falsification of documentation led to the administration of medication under inappropriate conditions, posing a risk to the resident's health.
Inadequate Grooming and Bathing Care for Residents
Penalty
Summary
The facility failed to provide adequate care and services to maintain good grooming for three residents, leading to unmet needs. Resident 62, admitted with chronic pain, was supposed to receive showers twice a week according to their care plan. However, documentation revealed that the resident only received three showers in May 2024, and the resident reported receiving only four showers a month, which was insufficient. Staff members confirmed that there was not enough time or staff to complete all showers as planned. Similarly, Resident 86, who required extensive assistance due to depression and paraplegia, was not consistently assisted with bathing and shaving. The resident preferred to be clean-shaven but was observed with facial hair, and staff acknowledged that the resident's personal hygiene needs were not met due to inconsistent staff assignments and lack of understanding of the resident's needs. Resident 98, who was cognitively intact and required assistance with most activities of daily living following a stroke, also experienced inadequate bathing care. The resident was scheduled for two showers a week but received only one bed bath and one sponge bath, with refusals documented on two occasions. Staff reported that there was insufficient time to complete all tasks due to staffing issues, and no additional attempts to bathe the resident were documented. The lack of documentation and follow-up on bathing refusals further highlighted the facility's failure to meet the resident's grooming needs.
Inadequate Bowel, Bladder, and Catheter Care
Penalty
Summary
The facility failed to provide adequate care for residents with bowel and bladder needs, as evidenced by the experiences of Resident 24. This resident, who was cognitively intact and admitted with a diagnosis of heart disease, reported waiting up to 30 minutes for staff to respond to call lights for bowel and bladder care. Observations confirmed delays in response times, with staff taking over 20 minutes to address the resident's needs, resulting in the resident experiencing frustration and emotional stress. Staff interviews corroborated the resident's account, highlighting staffing challenges that impeded timely care. Resident 86, admitted with depression and paraplegia, experienced issues with catheter care. The resident had a suprapubic catheter that was not properly monitored after a change, leading to the catheter slipping out during routine care. Staff were unaware of the catheter replacement and failed to conduct necessary assessments or obtain hospital records following an emergency room visit for catheter reinsertion. This lack of monitoring and documentation contributed to the deficiency in care. Resident 164, who had fragile skin and an allergy to aloe, suffered from inappropriate incontinent care. Despite a care plan specifying the use of non-aloe wipes, staff used the wrong wipes, causing redness and pain. The special wipes were not easily accessible, and there was no signage to remind staff of the resident's needs. Staff interviews revealed a lack of awareness and communication regarding the resident's specific care requirements, leading to the use of inappropriate products and subsequent discomfort for the resident.
Failure to Arrange Specialized Physician Appointments
Penalty
Summary
The facility failed to obtain specialized physician appointments for a resident, which was identified during a survey following a public complaint. The complaint, received on May 2, 2024, alleged that the facility did not arrange for the resident's nerve block procedure as per physician orders. The resident, admitted in June 2022, had diagnoses including chronic pain. A physician order dated January 13, 2023, indicated the need for referrals to neurology and cardiology for evaluation and a bilateral ultrasound-guided glenohumeral injection. On September 13, 2024, a staff member from Social Services acknowledged that the directive to schedule these appointments had not been addressed.
Significant Medication Error Due to Inaccurate Blood Pressure Documentation
Penalty
Summary
The facility failed to prevent a significant medication error involving a resident with a diagnosis of paraplegia. The resident was prescribed Baclofen, a muscle relaxant, to be administered three times a day, with instructions to hold the medication if the systolic blood pressure was less than 100. On the day of the incident, the resident's blood pressure was documented as 100/68, and the medication was administered. However, an investigation revealed that the actual blood pressure was 89/65, indicating that the medication should not have been given. The error occurred because Staff 20, a CMA, did not obtain the resident's blood pressure at the time of medication administration. Instead, she relied on the morning blood pressure reading and guessed the afternoon reading, which she then documented inaccurately. This action led to the administration of the medication despite the resident's chronic low blood pressure, which was significantly lower than the threshold for withholding the medication. Staff 19, an LPN, was informed by a CNA about the resident's low blood pressure, which prompted the investigation into the incident.
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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