Gresham Post Acute Care And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Gresham, Oregon.
- Location
- 405 Ne 5th Street, Gresham, Oregon 97030
- CMS Provider Number
- 385190
- Inspections on file
- 24
- Latest survey
- December 19, 2025
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at Gresham Post Acute Care And Rehabilitation during CMS and state inspections, most recent first.
A resident with a seizure disorder did not receive prescribed anti-seizure medication for several days due to pharmacy supply issues and lack of timely review of new medication orders by staff. Multiple staff members confirmed that medication orders were not properly reviewed or followed up, resulting in missed doses.
A resident with severe cognitive impairment and multiple medical conditions did not receive timely bowel care interventions as required by facility policy, resulting in seven days without a bowel movement, fecal impaction, dehydration, and a UTI. Staff did not notify the medical provider or implement the bowel management protocol as indicated, leading to the resident's transfer to the emergency department for treatment.
A resident admitted with a sacral pressure injury did not receive timely wound care, leading to the wound's progression from a deep tissue injury to unstageable. The facility's admission process failed to identify the wound, and no treatment was initiated until six days later, despite the resident's paralysis and risk factors. The facility's protocol for entering generic wound care orders was not followed, contributing to the delay in care.
The facility failed to ensure proper food storage and labeling in residents' personal refrigerators and did not enforce the use of hair restraints by kitchen staff. Two residents had unlabeled and undated food items in their personal refrigerators, and kitchen staff were observed without hair restraints during meal preparation, contrary to FDA guidelines.
The facility did not ensure that CNA staff received the required 12 hours of annual in-service training. A review showed that four CNAs had insufficient training hours, with one completing only 1.1 hours and the others none. The HR staff confirmed this, and the administrator acknowledged the need for a tracking system to monitor training hours.
The facility failed to inform residents and/or their responsible parties about the risks and benefits of psychotropic medications and did not obtain consent before administration for three residents. One resident was prescribed citalopram hydrobromide without documented consent, another received aripiprazole without consent, and a third was given fluoxetine without proper documentation of consent. Staff confirmed that it was their responsibility to review these details with residents prior to medication administration, which was not done.
The facility failed to provide written transfer notices with appeal rights to residents and their representatives and did not notify the Office of the State Long-Term Care Ombudsman of resident hospitalizations. Two residents with chronic respiratory failure were transferred to the hospital multiple times without receiving the required notifications. Interviews revealed staff were either unaware of the notification requirements or unclear about their responsibilities, and the Administrator confirmed the deficiency.
The facility failed to provide written notice of the bed hold policy to two residents during hospital transfers. One resident, with chronic respiratory failure and quadriplegia, was transferred three times without receiving the policy notice. Another resident, also with chronic respiratory failure, was sent to the hospital four times without the policy being provided. Staff admitted to not providing the policy, and the administrator confirmed the oversight.
A facility failed to ensure accurate MDS assessments for a resident, leading to an inappropriate diagnosis of schizoaffective disorder. The diagnosis was entered without involvement from a mental health practitioner and was inaccurately coded as schizophrenia on subsequent MDS assessments. The pharmacy review later identified the diagnosis as inappropriate, and the DNS acknowledged the error.
A facility failed to create a sufficient baseline care plan for a resident admitted with a pressure injury. The resident, with paralysis and a documented sacral pressure injury, was admitted without the injury being noted on the Clinical Admission Form. The Initial Care Plan did not address the pressure injury until five days post-admission. An LPN was unable to assess the sacrum during admission, and the resident's refusal of a full assessment was undocumented, with no follow-up by subsequent shifts.
The facility failed to update care plans for three residents, leading to potential unmet needs. A resident with epilepsy lacked required fall mats and daily shaving, another with brain compression was observed without a protective helmet, and a third resident's care plan inaccurately listed dialysis treatments that had ceased. Staff acknowledged the need for care plan revisions.
A Nurse Practitioner diagnosed a resident with schizoaffective disorder without involving a mental health professional, despite lacking the appropriate clinical discipline. The resident, with a history of anxiety and depression, was prescribed quetiapine based on this diagnosis, which was later questioned by a physician and pharmacist. The diagnosis remained unaddressed in the resident's records, and the Nurse Practitioner was no longer employed at the facility.
A facility failed to maintain oxygen equipment for a resident with COPD who required continuous oxygen therapy. Despite a physician's order to clean the oxygen concentrator and filter weekly, observations showed the equipment was dusty, and records lacked documentation of cleaning. The resident did not recall any cleaning, and staff confirmed the oversight.
A resident with anxiety and depression was prescribed quetiapine without documented clinical indications or a plan for evaluating its effectiveness. The dosage was increased multiple times without rationale, and a new diagnosis of schizoaffective disorder was added without a mental health professional's evaluation. The DNS could not provide supporting documentation, and the diagnosis was questioned by the pharmacist and physician.
Failure to Administer Anti-Seizure Medication as Ordered
Penalty
Summary
A resident with a history of seizures and respiratory failure was admitted to the facility with a physician's order for felbamate, an anti-seizure medication, to be administered twice daily. Despite this order, the medication was not administered for three days, resulting in five missed doses, due to complications in obtaining the medication from the pharmacy. Progress notes indicated staff were aware of the delay, but the medication was not delivered until several days after the order was written. Interviews with facility staff revealed that orders were not reviewed as required, and there was a lack of oversight in ensuring the medication was obtained and administered as prescribed. Staff also confirmed that when the Resident Care Manager was unavailable, other staff did not review new admission medications, contributing to the delay.
Failure to Prevent and Manage Constipation Resulting in Fecal Impaction
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent constipation for a resident with severe cognitive impairment, central cord syndrome, and toxic encephalopathy. The resident was admitted with significant care needs, including substantial to maximal assistance for toileting and was prescribed both polyethylene glycol and sennosides for constipation. Despite these interventions, the resident experienced a decline in oral intake and had no recorded bowel movements for seven consecutive days. According to the facility's Bowel Management policy, residents who do not have a bowel movement for three days should be placed on the bowel program and, if ineffective, the medical provider should be notified within 24 to 32 hours for further orders. Documentation and staff interviews revealed that the resident was not placed on the bowel program as required, and the medical provider was not notified of the ongoing constipation. Multiple staff members confirmed that the resident's lack of bowel movements should have triggered additional interventions and provider notification, but there was no evidence of such actions in the medical record. As a result of these omissions, the resident developed a fecal impaction, significant rectal distention, dehydration, and a urinary tract infection, necessitating emergency department evaluation and treatment. The medical provider was only contacted after seven days without a bowel movement, and new orders were obtained following the resident's return from the hospital. Staff and leadership interviews confirmed that the facility's bowel management protocol was not followed, and the required notifications and interventions were not implemented in a timely manner.
Failure to Initiate Timely Pressure Ulcer Treatment
Penalty
Summary
The facility failed to initiate treatment for a pressure injury present upon admission for a resident with a history of pressure injury to the sacrum. The resident was admitted with diagnoses including paralysis of the lower extremities, diabetes, and obesity. The hospital records indicated a new pressure injury to the sacrum, described as a deep tissue injury (DTI), was present before admission. However, the facility's Clinical Admission form did not identify the wound, and the admission orders did not include wound care instructions. The Braden Scale assessment inaccurately reported no sensory perception impairment, despite the resident's paralysis. The resident's care plan was updated several days after admission to address potential skin impairment, but no wound care was initiated until six days post-admission. Staff confirmed that the resident's pressure injury was not assessed or treated until the facility's certified wound specialist evaluated it, finding it unstageable and requiring debridement. The facility's protocol for entering generic wound care orders upon admission was not followed, and there was no documentation of the resident refusing a full assessment. The lack of timely wound care led to the progression of the pressure injury, necessitating medical intervention.
Deficiencies in Food Storage and Kitchen Sanitation
Penalty
Summary
The facility failed to ensure proper food storage and labeling in residents' personal refrigerators, as well as the use of appropriate hair restraints by kitchen staff during meal preparation. Resident 4, who was admitted with osteomyelitis and malnutrition, had a personal refrigerator containing several items that were not labeled or dated, including milk, pudding, and ranch dip. The resident reported that no one checked the temperatures or expiration dates of the items in their refrigerator. Staff 7, an LPN-Resident Care Manager, acknowledged that the items should have been dated or discarded, and removed the undated and expired foods. The facility administrator admitted that there was no policy or procedure for managing residents' personal refrigerators, attributing the oversight to staff turnover. Similarly, Resident 21, who was admitted with kidney disease and hypertension, had a personal refrigerator with unlabeled and undated items, including orange juice, yogurt, and chicken nuggets with sauce. The resident also confirmed that staff did not check the refrigerator for expired foods. Staff 7 again acknowledged the need for proper labeling and disposal of expired items. Additionally, during a lunch service observation, several kitchen staff members, including a dietary aide, cook, and dietary manager, were seen without hair restraints, contrary to the US FDA Food Code 2022 requirements. The dietary manager admitted that it was expected for all kitchen staff to wear hair restraints at all times.
Deficiency in CNA Annual In-Service Training
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistant (CNA) staff received the required 12 hours of annual in-service training. This deficiency was identified during an interview and record review, which revealed that four out of five randomly selected staff members did not meet the training requirements. Specifically, one CNA had only completed 1.1 hours of training, while the other three CNAs had not completed any training hours. The Human Resources staff confirmed the lack of training, and the facility administrator acknowledged the requirement for 12 hours of annual in-service training, noting the need for a tracking system to monitor training hours.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform residents and/or their responsible parties about the risks and benefits of psychotropic medications and did not obtain consent before administration for three residents. Resident 66, admitted with major depressive disorder, was prescribed citalopram hydrobromide without documented consent or information provided about the medication's risks and benefits until over a month after administration began. Staff confirmed that it was the nursing staff's responsibility to review these details with residents prior to medication administration, which was not done in this case. Similarly, Resident 26, with diagnoses of depression and anxiety, was prescribed aripiprazole without documented consent or information provided about the medication's risks and benefits until several years after the prescription was initiated. Additionally, Resident 14, admitted with anxiety disorder and major depressive disorder, received fluoxetine without documented consent or a review of the medication's risks and benefits. Staff verified that the consent documentation did not include fluoxetine, indicating a failure to ensure informed consent was obtained prior to administration.
Failure to Provide Transfer Notices and Notify Ombudsman
Penalty
Summary
The facility failed to provide written transfer notices with appeal rights to residents and their representatives, and did not notify the Office of the State Long-Term Care Ombudsman of resident hospitalizations. This deficiency was identified for two residents who were transferred to the hospital multiple times. Resident 44, admitted with chronic respiratory failure and quadriplegia, was transferred to the hospital on three occasions without receiving the required transfer notices or having the Ombudsman notified. Similarly, Resident 42, also with chronic respiratory failure, was sent to the hospital four times without the necessary notifications being provided. Interviews with facility staff revealed a lack of awareness and responsibility regarding the notification requirements. The Social Service Director was unaware of the need to notify the Ombudsman, while another staff member knew of the requirement but did not know who was responsible for it. The Administrator confirmed that the facility did not provide the required written notices or inform the Ombudsman of the transfers, indicating a systemic issue in the facility's processes for handling resident transfers and discharges.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide residents with a written notice of the bed hold policy at the time of transfer to the hospital, affecting two residents reviewed for hospitalization. Resident 44, admitted in November 2022 with chronic respiratory failure and quadriplegia, was transferred to the hospital on three occasions in 2024. There was no evidence in the health record that a written notice of the bed hold policy was provided during these transfers. Staff 26, the Social Service Director, admitted unfamiliarity with the bed hold policy and confirmed that no written notice was given to Resident 44 during the transfers. Similarly, Resident 42, admitted in March 2024 with chronic respiratory failure, was sent to the hospital four times in 2024. Again, there was no documentation indicating that the resident or their representative received a written notice of the bed hold policy. Staff 6, an LPN, stated that he did not provide the policy to residents or their representatives at the time of transfer. The facility's administrator confirmed these findings, acknowledging the lack of written notification provided to residents or their representatives regarding the bed hold policy during hospital transfers.
Inaccurate MDS Assessment and Diagnosis
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for a resident, which led to an inappropriate diagnosis being recorded. The resident, who was readmitted with diagnoses of generalized anxiety disorder and major depressive disorder, was suggested to have schizoaffective disorder by a physician. However, there was no evidence that a mental health practitioner was involved in confirming this diagnosis, nor was there documentation that the resident met the diagnostic criteria for schizoaffective disorder. Despite this, the diagnosis was entered into the medical record by a former nurse practitioner. The inappropriate diagnosis was further compounded when it was inaccurately coded as schizophrenia on subsequent MDS assessments. The pharmacy review later identified that the resident had no history of schizoaffective disorder, and the diagnosis was deemed inappropriate. The Director of Nursing Services acknowledged that the diagnosis should not have been coded on the MDS, highlighting a failure in ensuring accurate mental health diagnoses and assessments for the resident.
Failure to Address Pressure Injury in Baseline Care Plan
Penalty
Summary
The facility failed to ensure a baseline care plan was sufficient to meet the needs of a resident admitted with a pressure injury. Resident 173 was admitted with a recent onset of paralysis of the lower extremities and a documented history of a pressure injury to the sacrum, identified during hospitalization. The hospital records indicated the presence of a deep tissue injury (DTI) on the sacrum, requiring specific treatments such as protective ointment, foam dressing, frequent repositioning, and pressure reduction. However, the facility's Clinical Admission Form did not document the presence of this wound, and the Initial Care Plan did not address the actual pressure injury until five days after admission. Staff 4, an LPN, stated that she completed the resident's admission but was unable to visualize the sacrum at that time, despite receiving information about the pressure wound from the hospital. The resident refused a full assessment upon admission, but this refusal was not documented, and subsequent shifts did not follow up. Staff 2 (DNS) and Staff 3 (LPN, Resident Care Manager) confirmed that the Baseline Care Plan was based on the Clinical Admission Form data, which lacked the necessary information about the pressure injury.
Care Plan Inaccuracies for Three Residents
Penalty
Summary
The facility failed to ensure care plans were revised to accurately reflect the needs of three residents, leading to potential risks for unmet needs. Resident 19, admitted with dysphagia and epilepsy, had a care plan indicating the use of bilateral fall mats and daily shaving. However, observations revealed the absence of fall mats and unshaven facial hair, contrary to the care plan. Staff interviews indicated that the resident no longer required fall mats and was not shaved daily, highlighting a discrepancy between the care plan and the resident's current needs. Resident 66, with a diagnosis of brain compression, had a care plan requiring a protective helmet when out of bed. Observations showed the resident without a helmet while in a wheelchair, and staff were unclear about the helmet's necessity, indicating a need for care plan revision. Resident 67, admitted with acute kidney failure, had a care plan for dialysis treatments, but the resident reported cessation of dialysis weeks prior, which was not updated in the care plan. The Director of Nursing Services acknowledged the need for care plan revisions for these residents.
Inappropriate Diagnosis by Nurse Practitioner
Penalty
Summary
The facility failed to ensure that a Nurse Practitioner, identified as Former Staff 34, adhered to the professional standards of quality by diagnosing a resident with a condition outside of their clinical discipline. The Nurse Practitioner, accredited as an Adult-Gerontology Primary Care Nurse Practitioner (AGPCNP), diagnosed a resident with schizoaffective disorder without involving a mental health professional. This diagnosis was made despite the resident's history of generalized anxiety disorder and major depressive disorder, and without clear evidence that the resident met the diagnostic criteria for schizoaffective disorder. The diagnosis was questioned by both a physician and a pharmacist, who noted the inappropriateness of the diagnosis and the lack of a history of schizoaffective disorder in the resident's medical records. The resident, who was readmitted to the facility with significant anxiety and depression, was prescribed quetiapine, an antipsychotic medication, based on the inappropriate diagnosis. Despite recommendations from a pharmacy review to address the issue, no response or corrective action was documented, and the diagnosis remained on the resident's active diagnoses list at the time of the survey. The Director of Nursing Services (DNS) confirmed the diagnosis was made by the Nurse Practitioner without mental health professional involvement and acknowledged the concerns raised by the pharmacist and physician, but no further follow-up was provided. Former Staff 34 was no longer employed at the facility at the time of the survey.
Failure to Maintain Oxygen Equipment
Penalty
Summary
The facility failed to maintain oxygen equipment for a resident with chronic obstructive pulmonary disease, who required continuous oxygen therapy. The resident was admitted in June 2024 and was cognitively intact. A physician's order from early June 2024 specified that the resident's oxygen concentrator and filter should be cleaned every Tuesday night shift. However, observations in late August 2024 revealed that the oxygen concentrator was covered in dust, and the external filter had a thick gray layer of dust. The resident reported not recalling any staff cleaning the equipment during their stay. Review of the Treatment Administration Records (TAR) for June, July, and August 2024 showed no documentation indicating that the night shift staff cleaned the concentrator and filter as ordered. Staff interviews confirmed the responsibility of the night shift to perform this task, and acknowledgment was made that the equipment had not been cleaned as expected.
Failure to Justify Antipsychotic Medication Use
Penalty
Summary
The facility failed to identify clinical indications for the use of an antipsychotic medication for a resident diagnosed with cancer, generalized anxiety disorder, and major depressive disorder-recurrent. The resident was readmitted in October 2023, and their behavior was monitored, showing episodes of difficulty sleeping but no other significant behaviors or concerns. Despite this, on March 1, 2024, quetiapine, an antipsychotic medication, was prescribed for depression without documented clinical indications or a plan for evaluating its effectiveness. The dosage was increased multiple times without clinical rationale, and a new diagnosis of schizoaffective disorder was added without support from a mental health professional's evaluation. The facility's documentation did not provide a rationale for the prescription or dosage increases of quetiapine, nor did it involve a mental health professional in diagnosing schizoaffective disorder. The Director of Nursing Services (DNS) was unable to provide supporting documentation for the prescription, and the diagnosis was questioned by both the pharmacist and physician. The lack of documentation and professional involvement placed the resident at risk for unnecessary use of psychotropic medication.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
