Hillside Heights Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Eugene, Oregon.
- Location
- 1201 Mclean Blvd., Eugene, Oregon 97405
- CMS Provider Number
- 385046
- Inspections on file
- 23
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Hillside Heights Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not complete timely investigations for two residents: one who experienced an unwitnessed fall and another who was diagnosed with a sexually transmitted infection despite significant cognitive impairment. In both cases, required investigations into the incidents were either delayed or not documented, contrary to facility expectations.
A resident with a history of unsteadiness and traumatic brain injury experienced multiple falls, including one unwitnessed fall caused by malfunctioning bed brakes. Although the care plan included interventions for fall prevention, there was no documentation of required monthly bed brake checks or related maintenance work orders. Staff confirmed the brakes were not functioning at the time of the incident, and it was expected that staff check bed brakes before leaving the room.
A resident with dysphagia and dementia, who was care planned to need supervision or touch assistance with eating, was observed left alone with a meal tray and received no assistance during mealtime. Staff later removed the tray with most of the food uneaten, and confirmed they were aware of the resident's need for eating assistance but could not recall providing it.
A resident with a history of stroke and anxiety experienced delays in obtaining an ordered STI risk panel due to incomplete laboratory requisitions and issues with specimen collection. Despite urgent clinical symptoms and repeated attempts, the required testing was not completed, and the resident was eventually sent to the emergency department for further evaluation.
The facility failed to provide menus for residents to select their preferred meals, affecting their ability to make choices. Despite a change to a weekly menu system, residents reported not receiving these menus, leading to dissatisfaction and unmet preferences. Staff confirmed the change and the resulting resident dissatisfaction.
The facility's kitchen was found to have several sanitation and food storage deficiencies, including undated and improperly stored food items in the walk-in refrigerator and freezer, and a lack of temperature monitoring for a small refrigerator containing resident food items. The kitchen area also had unclean surfaces and floors, with food crumbs and debris present. Staff were unaware of temperature monitoring procedures, and the Dietary Manager acknowledged these issues.
An LPN at the facility failed to demonstrate appropriate competencies in infection control and insulin administration. The LPN did not clean the glucometer after CBG checks and did not prime the insulin pen as per manufacturer instructions. The LPN, new to the facility and in her first nursing job, was not aware of these procedures and had not undergone competency checks, as confirmed by the DNS.
The facility did not have an RN available for at least eight consecutive hours on three days, risking delayed nursing assessments for residents. This was confirmed through staff reports and acknowledged by the administrator.
The facility failed to maintain proper storage temperatures for a medication refrigerator, with temperatures reaching 73°F, affecting flu vaccines and insulin. Additionally, two open Tresiba insulin pens lacked open dates, and a treatment cart was left unlocked twice, risking unauthorized access. Staff acknowledged these issues.
The facility failed to ensure a homelike environment for residents, with issues such as a loud air conditioner, a burned-out bathroom light, peeling window paint, and a strong urine odor in a resident's room and wheelchair. Staff acknowledged these issues, but there was no documentation of corrective actions taken.
A resident prescribed Trazodone for insomnia did not receive information about the medication's risks and benefits, hindering informed decision-making. The resident, with a history of depression, anxiety, and insomnia, was unaware of any discussion or consent regarding the medication. An LPN confirmed the lack of documentation on this matter.
The facility failed to document advance directives for three residents, including one with depression and two with diabetes. The Director of Social Services confirmed the lack of documentation and was unable to provide evidence that advance directives were offered or reviewed with the residents or their families.
The facility failed to provide proper respiratory care for two residents, leading to deficiencies in oxygen administration and equipment maintenance. One resident's oxygen concentrator filters were not cleaned weekly as ordered, while another resident received oxygen at a higher rate than prescribed, with tubing not changed regularly, resulting in crusty debris. Staff confirmed the lack of documentation and absence of a facility policy for these tasks.
A facility failed to clean a community use CBG glucometer between resident uses, risking bloodborne illness. An LPN was observed not cleaning the glucometer after use and admitted to cleaning it only at shift start and end, without knowing the location of the required wipes. The DNS confirmed the expectation for cleaning with bleach wipes between uses, and a Corporate RN noted residents requiring regular and PRN CBG checks.
The facility failed to maintain essential kitchen equipment in safe operating condition, as the walk-in refrigerator's door handle was missing. Dietary staff acknowledged the issue, but the handle remained unrepaired during a follow-up visit. A dietitian noted the need to locate and reattach the handle.
Failure to Timely Investigate Abuse Allegation and Resident Fall
Penalty
Summary
The facility failed to investigate a potential case of abuse and did not investigate a fall in a timely manner for two residents. One resident, admitted with unsteadiness on feet and a traumatic brain injury, experienced an unwitnessed fall while attempting to go outside. The investigation into this fall was not completed until nearly two weeks later, despite facility expectations that such investigations be completed within five days. Another resident, admitted with a history of stroke, anxiety, and significant cognitive impairment, was diagnosed with trichomonal vaginitis, a sexually transmitted infection, after presenting with persistent symptoms and being sent to the emergency department. Despite the diagnosis and a public complaint alleging a sexually transmitted disease, there was no documentation in the clinical record of an investigation into potential sexual abuse for this resident. Staff confirmed that an investigation into possible sexual abuse was expected but not completed.
Failure to Maintain Safe Environment Due to Malfunctioning Bed Brakes
Penalty
Summary
A deficiency occurred when the facility failed to maintain a safe environment free from accident hazards for a resident admitted with unsteadiness on feet and a traumatic brain injury. The resident experienced two falls on the day of admission, and a subsequent unwitnessed fall occurred when the resident rolled out of bed due to malfunctioning bed brakes. Although the baseline care plan included interventions such as a PT consultation and monitoring for changes in condition, the bed brakes in the resident's room were not functioning properly at the time of the fall. Maintenance staff stated that bed brakes were supposed to be checked monthly, but there was no documentation to verify these checks or any work orders related to the malfunctioning brakes during the relevant period. Nursing staff confirmed the bed brakes were not working at the time of the incident, and the DNS stated that staff were expected to check bed brakes before leaving a resident's room.
Failure to Provide Eating Assistance as Care Planned
Penalty
Summary
A resident with diagnoses of dysphagia and dementia, admitted in February 2025, was care planned to require supervision or touch assistance with eating due to an ADL self-care performance deficit. On observation, the resident was left alone in bed with a food tray and was unable to answer questions, with no staff present in the room. Staff later entered the room, asked if the resident was finished eating, and removed the tray despite approximately 90 percent of the food remaining. The staff member assigned to the resident confirmed knowledge of the care plan requiring one-person assistance and supervision for eating but could not recall if she had provided this assistance during the meal. The DNS confirmed that the staff working with the resident at the time did not know the resident and acknowledged the resident required assistance to eat.
Failure to Timely Process Physician Laboratory Orders
Penalty
Summary
The facility failed to process a physician's laboratory order in a timely manner for a resident admitted with a history of stroke and anxiety. A physician ordered a sexually transmitted infection (STI) risk panel, but the laboratory requisition was incomplete, lacking the necessary test code and name. The laboratory report indicated that no suitable specimen was received and requested clarification on test requirements. Despite the urgency noted on the requisition, the required Aptima swab was not provided, and the test was not performed. Subsequent clinical notes documented that the resident experienced ongoing symptoms, including foul-smelling vaginal discharge and new-onset hallucinations. The resident completed a course of antibiotics for a urinary tract infection (UTI) without improvement. Staff reported difficulties obtaining the required STI testing due to laboratory refusals and facility budget constraints. The Director of Nursing Services was unable to clarify what occurred with the laboratory results, and ultimately, the resident was sent to the emergency department for further evaluation.
Failure to Provide Menus for Resident Meal Preferences
Penalty
Summary
The facility failed to ensure a system was in place to honor resident food preferences, affecting four sampled residents. The deficiency was identified through observations, interviews, and record reviews. Residents, including those with diabetes and heart disease, reported not receiving menus to select their preferred meals. The facility had recently changed its menu system from providing daily menus to weekly menus distributed on Fridays. However, residents stated they did not receive these weekly menus, and staff confirmed that the change had upset several residents as it removed their ability to choose between meal options. Staff members, including CNAs and the dietitian, acknowledged the change in the menu system and the resulting dissatisfaction among residents. The facility's administrator stated that the change was discussed in Resident Council and at a food committee, but residents reported not being informed of these changes. The lack of menu distribution led to residents receiving meals without the opportunity to make choices, impacting their satisfaction and potentially their nutritional needs.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during an inspection. In the walk-in refrigerator, there were several issues including an opened and undated plastic container with pickle spears, a cardboard box of dark brown bananas, and an open stick of margarine exposed to air and undated. The floor of the refrigerator was littered with food crumbs, brown splatters, and various small debris. Similarly, the walk-in freezer contained a bag of frozen tapioca hot dog buns with an expiration date of 12/22/22, and several opened and undated bags of frozen chicken strips, hamburger patties, and veggie vegan patties. A zip lock bag labeled pizza sausage was found to be freezer burnt with an illegible date. The freezer floor also had food crumbs and brown splatters of debris. In the main kitchen area, a wire rack next to a garbage can had metal containers with splatters of debris, and the bottom shelf of the steam table, where clean pots and pans were stored, had drips of white and brown debris. A wire shelf containing clean bowls was covered with a sticky brown film, and the floor throughout the main kitchen area was covered with food crumbs, brown splatters, and various small debris. Additionally, a small refrigerator containing juice, milk, and yogurt did not have a temperature log, and staff members were unaware of any temperature monitoring for this refrigerator. The Dietary Manager acknowledged these findings, indicating a lack of proper monitoring and maintenance of sanitary conditions in the kitchen.
LPN Lacks Competency in Infection Control and Insulin Administration
Penalty
Summary
The facility failed to ensure that a Licensed Practical Nurse (LPN), identified as Staff 13, possessed the necessary competencies and skills for infection control during capillary blood glucose (CBG) checks and insulin administration. On the specified date, Staff 13 was observed obtaining a CBG for a resident and subsequently placing the glucometer in the treatment cart without cleaning it. Continuous observations revealed that Staff 13 administered medications and insulin to multiple residents without cleaning the glucometer. Staff 13, who had been working at the facility for one month and was in her first nursing job, stated that she cleaned the glucometers only at the beginning and end of her shift and was not aware of any competency checks by the facility. Additionally, Staff 13 did not follow the manufacturer's instructions for administering Novolog insulin, as she failed to prime the insulin pen with two units before drawing up the insulin for administration. When questioned, Staff 13 acknowledged her lack of knowledge regarding the need to prime the insulin pen and reiterated that she had not undergone competency checks. The Director of Nursing Services (DNS), identified as Staff 2, confirmed that nursing competencies had not been completed for Staff 13, highlighting a lapse in ensuring staff were adequately trained and competent in their duties.
Failure to Ensure RN Coverage for Eight Consecutive Hours
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was available for at least eight consecutive hours per day on three specific days within a 31-day period. This deficiency was identified through a review of the Direct Care Staff Daily Reports, which showed no RN coverage on the dates of August 20, 21, and 22, 2024. The absence of RN coverage on these days placed residents at risk for delayed nursing assessments. The facility's administrator acknowledged the lack of RN coverage on the identified dates during an interview conducted on August 29, 2024.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to maintain proper storage temperatures for one of its medication storage refrigerators, as evidenced by temperature logs from August 2024. The logs indicated that the refrigerator on the East Hall exceeded the recommended temperature range of 36 to 46 degrees Fahrenheit on multiple occasions, reaching as high as 73 degrees Fahrenheit on August 21, 2024. This refrigerator contained flu vaccines and insulin, which require specific temperature conditions to maintain their efficacy. Staff 2, the Director of Nursing Services (DNS), acknowledged the temperature discrepancies during an observation on August 30, 2024. Additionally, the facility did not ensure proper labeling and security of treatment carts. On August 29, 2024, two open Tresiba insulin pens were found in the East Hall treatment cart without open dates, which was confirmed by an LPN. Furthermore, the same treatment cart was observed to be unlocked on two separate occasions, on August 26 and August 27, 2024, with residents and staff walking by. Staff 14, an LPN, admitted to leaving the cart unsecured both times, acknowledging that it should have been locked at all times to prevent unauthorized access to medications.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several deficiencies observed during the survey. Resident 19's room had an air conditioner unit that emitted a loud, high-pitched squeak, which was acknowledged by the facility's Administrator and Maintenance Director. Resident 6's bathroom light was burned out for about a week, despite being reported by a Nursing Assistant, and had not been fixed by the time of the survey. Additionally, Resident 27's room had a window with peeling paint and exposed particle board, and Resident 33's room had window trim pieces that were separated with exposed edges, both of which were acknowledged by the facility's staff. Resident 32's room and wheelchair were noted to have a strong odor of urine, which was acknowledged by multiple staff members, including CNAs, an LPN, and the Housekeeping staff. The resident was incontinent and wore multiple briefs and incontinent pads, contributing to the odor. Despite the night shift being responsible for cleaning wheelchairs, there was no documentation of the cleaning being done or of the resident refusing the cleaning. The facility's DNS and Corporate RN also acknowledged the persistent urine odor in the resident's room and wheelchair.
Failure to Inform Resident of Medication Risks and Benefits
Penalty
Summary
The facility failed to provide risk and benefit information for a psychotropic medication to a resident, which was necessary for making informed decisions about their care. The resident, admitted in July 2022 with diagnoses of depression, anxiety, and insomnia, was prescribed Trazodone for insomnia as per a physician's order dated January 24, 2024. Upon review of the resident's medical record, there was no documentation indicating that the risks and benefits of Trazodone were discussed with the resident. During an interview on August 27, 2024, the resident stated they did not recall discussing the risks and benefits of the medication with facility staff or signing a consent form. On August 29, 2024, a Licensed Practical Nurse (LPN) Unit Manager confirmed the absence of evidence that the risks and benefits were reviewed with the resident.
Failure to Document Advance Directives for Residents
Penalty
Summary
The facility failed to obtain and document information related to advance directives and health care decisions for three of four sampled residents. Resident 17, admitted in July 2016 with a diagnosis of depression, had no evidence in their clinical record of being provided with information on the right to formulate an advance directive. This was confirmed by the Director of Social Services. Resident 34, admitted in June 2024 with a diagnosis of diabetes, also had no documentation indicating that an advance directive was offered or reviewed with the resident or their family. The Director of Social Services was unable to recall or provide documentation of this process. Similarly, Resident 37, admitted in July 2022 with a diagnosis of diabetes, had no documentation of an advance directive being offered or reviewed, and the Director of Social Services could not provide evidence of this having occurred.
Deficiencies in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents, leading to deficiencies in oxygen administration and equipment maintenance. Resident 6, who was admitted in 2018 with chronic respiratory failure and hypoxia, had a physician order for weekly changes of the oxygen concentrator filter. However, observations on 8/27/24 revealed that the filters were dusty, indicating they had not been cleaned as required. Staff interviews confirmed that the responsibility for cleaning the filters was assigned to the evening nurse, but the task was not completed, as acknowledged by the Director of Nursing Services. Resident 10, admitted in 2014 with respiratory failure, was prescribed supplemental oxygen at 2 liters per minute to maintain oxygen levels above 90%. Observations from 8/26/24 to 8/29/24 showed the resident receiving oxygen at 3 liters per minute, contrary to the physician's order. Additionally, the oxygen tubing was not changed weekly, resulting in crusty debris on the nasal cannula. Staff confirmed the lack of documentation for tubing changes and acknowledged the absence of a facility policy for cleaning or changing oxygen tubing, contributing to the oversight.
Failure to Clean Glucometer Between Uses
Penalty
Summary
The facility failed to ensure proper cleaning and sanitization of a community use CBG glucometer between resident uses, which placed residents at risk for bloodborne illness. During an observation, an LPN was seen obtaining a CBG for a resident and then placing the glucometer back in the treatment cart without cleaning it. The LPN continued to pass medication and administer insulin to multiple residents without cleaning the glucometer. The LPN stated that she cleaned the glucometers at the beginning and end of her shift with purple wipes, but did not know where the wipes were located, and they were not on the treatment cart. The Director of Nursing Services stated that the expectation was for staff to clean glucometers with bleach wipes between every use. A Corporate RN confirmed that there were residents on the hall who required regular and PRN CBG checks.
Failure to Maintain Safe Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, specifically the walk-in refrigerator. On August 26, 2024, an observation revealed that the door handle to exit the refrigerator was missing. A dietary staff member stated that the handle had fallen off and was unsure of its whereabouts. The Dietary Manager acknowledged the issue and confirmed that the handle needed repair. A follow-up visit on August 28, 2024, showed that the door handle was still missing. On August 30, 2024, a dietitian mentioned that the staff needed to locate the handle and reattach it.
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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