Hillsboro Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hillsboro, Oregon.
- Location
- 1778 Ne Cornell Road, Hillsboro, Oregon 97124
- CMS Provider Number
- 385217
- Inspections on file
- 24
- Latest survey
- August 12, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Hillsboro Health & Rehabilitation Center during CMS and state inspections, most recent first.
Staff observed two cognitively impaired residents engaging in intimate behaviors, including inappropriate touching and offering money, and determined through evaluation that neither could consent to such activity. Despite these findings, the incident was not reported to the State Agency as required, and the administrator confirmed the lack of reporting.
Two residents with cognitive impairments, both lacking capacity to consent to sexual activity, were observed by staff engaging in intimate behaviors, including kissing and inappropriate touching. Staff separated the residents, but no investigation into the incidents was conducted, and the administrator could not provide evidence of any follow-up.
A resident with hemiplegia and hemiparesis, who used an electric wheelchair and was care-planned for a seat belt, was found on the floor with a leg laceration after sliding out of the wheelchair. Staff were aware the seat belt was too small and could not be used, but did not report or address the issue, and there was uncertainty among staff about the care plan requirements at the time of the incident.
A resident with severe cognitive impairment and documented preferences for reading and other leisure activities did not have a care plan or Kardex that included individualized activity interventions. Staff were unaware of the resident's specific interests, and observations showed the resident without access to preferred activities or materials, resulting in unmet psychosocial needs.
A resident with impaired hand control and a need for supervision with personal hygiene was not provided assistance with shaving as outlined in the care plan. Staff confirmed that the resident was unable to shave independently and was not offered help as required, resulting in inadequate grooming and hygiene care.
A resident with severe liver disease was prescribed two tablets of oxycodone for pain levels of eight to ten, but staff repeatedly administered this dose for lower pain scores, sometimes without accurately assessing pain. Multiple staff confirmed they did not follow the physician's order, and the DON acknowledged the orders were not implemented as required.
A resident with COPD and other chronic conditions experienced significantly low oxygen saturations, which were repeatedly reported by a CNA to an LPN and a Resident Care Manager. Despite standing orders and care plan directives, staff delayed both the administration of oxygen and the resident's transfer to the hospital. The resident was later diagnosed with hypoxic respiratory failure, and facility leadership confirmed that timely respiratory interventions were not provided.
A resident with severe cognitive impairment and high risk for pressure ulcers did not receive required weekly skin observations or timely wound care. Staff failed to document new skin impairments, did not act on a hospice aide's note about a new wound, and did not implement a wound dressing order. The pressure ulcer was discovered by hospice staff before facility staff, and the facility's investigation confirmed lapses in skin/wound management and communication.
The facility did not accurately post RN staffing information on several days, as confirmed by the staffing coordinator, resulting in incorrect nurse staffing data being displayed.
Failure to Report Alleged Abuse Involving Cognitively Impaired Residents
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency involving two residents with cognitive impairments. One resident, admitted with dementia and a BIMS score indicating severe cognitive impairment, and another resident with a moderate cognitive impairment, were both determined through Sexual Capacity Evaluations to lack the cognitive ability to consent to sexual activity. On two occasions, staff observed these residents engaging in intimate behaviors, including kissing and inappropriate touching, with one resident offering money to the other. Staff intervened and separated the residents each time. Despite these observations and the completion of sexual consent evaluations confirming both residents' inability to consent, there was no evidence that the incident was reported to the State Agency as required. The administrator acknowledged the lack of reporting and confirmed it was his responsibility to do so. The failure to report the suspected abuse placed the residents at risk.
Failure to Investigate Alleged Abuse Between Cognitively Impaired Residents
Penalty
Summary
The facility failed to investigate allegations of abuse involving two residents with cognitive impairments. One resident with severe dementia and another with moderate cognitive impairment were both determined, through Sexual Capacity Evaluations, to lack the capacity to consent to sexual activity. On two occasions, staff observed these residents engaging in intimate behaviors, including kissing and inappropriate touching, with one resident offering money to the other. Staff intervened and separated the residents, but there was no evidence that an investigation into the incidents was conducted. The administrator confirmed that it was his responsibility to complete such investigations but was unable to locate any documentation that an investigation had occurred.
Failure to Provide Adequate Supervision and Assistance Devices to Prevent Resident Accident
Penalty
Summary
A deficiency occurred when a resident with hemiplegia and hemiparesis following a stroke, who used an electric wheelchair and was care-planned for a seat belt-gait belt, was not provided with adequate supervision and assistance devices to prevent accidents. The care plan specified the use of a seat belt, but staff were unable to secure it around the resident because it was too small, and this issue was known but not reported or addressed. The resident subsequently slid out of the wheelchair, sustained a leg laceration, and had to call emergency services for assistance after yelling for help without response. Staff interviews revealed uncertainty about the care plan requirements and whether the seat belt was in use at the time of the fall, indicating a lack of adherence to the care plan and communication regarding the resident's safety needs.
Failure to Develop Resident-Centered Activity Care Plan
Penalty
Summary
The facility failed to develop a resident-centered care plan for a resident with severe cognitive impairment and a diagnosis of dementia. The resident's Minimum Data Set (MDS) and activity assessments indicated preferences for reading, music, animals, fresh air, and specific types of books, such as murder mystery and suspense. Despite these documented preferences, the care plan and Kardex lacked specific interventions or directions for staff to provide or facilitate these activities. Observations over several days showed the resident in bed without access to reading materials, music, or other preferred activities, and staff interviews revealed they were unaware of the resident's specific interests beyond a general preference to stay in bed. Activity participation records showed the resident did not attend group activities like Bingo and primarily engaged with reading materials when available, but there was no consistent provision of preferred books or other leisure activities. Staff responsible for activities and direct care confirmed that the care plan and Kardex did not include individualized activity preferences or instructions, and the resident was not regularly offered opportunities for meaningful engagement as indicated by their documented interests and needs.
Failure to Provide Required Assistance with Grooming and Hygiene
Penalty
Summary
A deficiency was identified when a resident with nephrogenic diabetes insipidus and ataxia, who was cognitively intact but required supervision or touching assistance for personal hygiene, was not provided necessary care for grooming. The resident's care plan specified the need for maximal or substantial assistance with showers on specific days and supervision or touch assistance for grooming and personal hygiene. During an observation, the resident was noted to have a thick cluster of dark hairs on the chin and reported being unable to shave independently due to impaired hand control. The resident stated that assistance with shaving was supposed to be provided on shower days but was not offered that week. Interviews with CNAs and an LPN confirmed that the resident was unable to shave independently and was expected to receive assistance with shaving, particularly on shower days. Staff acknowledged that the resident was not offered shaving assistance as required, and the Director of Nursing Services confirmed that residents needing ADL assistance should receive it automatically, without having to request it. The failure to provide this assistance resulted in the resident not receiving appropriate grooming and hygiene care.
Failure to Follow Opioid Dosing Parameters for a Resident
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs by not adhering to physician orders regarding the administration of opioid pain medication. The resident, who had severe liver disease with ascites, was prescribed two tablets of oxycodone every four hours as needed for pain levels of eight to ten out of ten. However, medication administration records showed that staff repeatedly administered two tablets of oxycodone for pain levels below the prescribed threshold, including pain levels as low as three. Multiple staff members confirmed that they either did not assess the resident’s pain level accurately or administered the higher dose regardless of the actual pain score. Interviews with staff revealed that some did not consistently ask the resident for their pain level, instead recording or assuming higher pain scores to justify administering two tablets. One staff member admitted to mistakenly giving two tablets when only one should have been given, and another stated that the resident was clear in communicating pain but still received the higher dose on several occasions. The Director of Nursing confirmed that physician orders were not followed as required, resulting in the resident receiving more opioid medication than indicated by the order parameters.
Failure to Provide Timely Respiratory Intervention for Resident with Low Oxygen Saturation
Penalty
Summary
A resident with a history of COPD, chronic kidney disease, and atrial fibrillation was admitted to the facility and had standing orders for supplemental oxygen to maintain saturations above 89%, with instructions to increase oxygen up to 2 liters before notifying a provider. The resident's care plan directed staff to monitor for breathing difficulties and signs of acute respiratory insufficiency. On the morning in question, the resident was found to have oxygen saturations as low as 64%, which were confirmed by repeated checks. The CNA reported these findings multiple times to both an LPN and the Resident Care Manager/LPN, but the Resident Care Manager delayed addressing the concern, and no oxygen was administered to the resident at that time. The resident was not transferred to the hospital until several hours later, where they were diagnosed with hypoxic respiratory failure. Staff interviews confirmed that the low oxygen saturations were reported and recognized, but appropriate interventions, including the administration of oxygen, were not initiated in a timely manner. Facility leadership acknowledged that the standard of practice would have been to reassess the resident, provide oxygen, and complete a full set of vitals before determining whether to send the resident to the hospital or contact the physician. The lack of timely evaluation and intervention was identified as a deficiency in providing appropriate and timely respiratory care.
Failure to Conduct Weekly Skin Observations and Timely Pressure Ulcer Treatment
Penalty
Summary
Facility staff failed to conduct weekly skin observations and timely evaluations for a resident with severe cognitive impairment, Alzheimer's disease, and diabetes mellitus, who was at high risk for pressure ulcers and dependent on staff for bed mobility. The resident's care plan required frequent repositioning, regular skin inspections during care, and prompt notification of new skin conditions. Despite these requirements, weekly skin observation records showed significant gaps, with no new skin impairments documented over several weeks, and a 35-day lapse between observations during which a new, unstageable pressure ulcer developed on the resident's coccyx. A hospice bath aide first noted an open sore on the resident's bottom, and hospice staff left a handwritten note for facility staff regarding the new wound. However, the note was not acted upon, as the responsible nurse was absent and did not ensure the information was communicated to oncoming staff. Progress notes and interviews revealed that a wound dressing order was placed but not implemented, and there was no prior written order for a dressing. The facility's investigation confirmed a breakdown in the skin/wound management process and a lack of nurse follow-up regarding treatment orders. Interviews with staff indicated that the hospice provider discovered the wound before facility staff did, and that required weekly skin observations and documentation were not completed as per protocol. The delay in identifying and treating the pressure ulcer resulted from missed observations, lack of communication among staff, and failure to follow up on treatment orders, leading to inadequate evaluation and delayed care for the resident's pressure ulcer.
Inaccurate RN Staffing Information Posted
Penalty
Summary
The facility failed to ensure that the Direct Care Staff Daily Report (DCSDR) postings accurately reflected Registered Nurse (RN) staffing for five out of seven days reviewed. Record review showed that the posted RN coverage was inaccurate on multiple specific dates. This was confirmed by the staffing coordinator, who acknowledged the discrepancies in the DCSDR postings for those days. No information was provided regarding the involvement of specific residents or their medical conditions at the time of the deficiency.
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.
