Hood River Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Hood River, Oregon.
- Location
- 729 Henderson Road, Hood River, Oregon 97031
- CMS Provider Number
- 385104
- Inspections on file
- 19
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Hood River Post Acute during CMS and state inspections, most recent first.
A facility failed to store foods at appropriate temperatures, with a refrigerator consistently exceeding the required 41 degrees F. Despite recorded temperature discrepancies, no corrective action was taken by the Dietary Director, leading to an immediate jeopardy situation as raw meat stored at unsafe temperatures was planned for use in an upcoming meal.
The facility did not ensure that contact information for State agencies and the LTCO poster were accessible to residents in one of the two units observed. The postings were only available outside the locked enhanced care unit (ECU), and a resident reported being unaware of how to access this information and unable to leave the ECU without staff assistance. The administrator confirmed that ECU residents could not access the postings without help.
The facility failed to maintain sanitary laundry practices, as observed when a staff member delivered clean resident clothing using an uncovered laundry cart in two halls. The cart was left unattended during delivery, which was acknowledged by the Administrator as improper practice.
A facility failed to obtain consent before administering mirtazapine to a resident with dementia and a fracture, as revealed by a review of health records. The resident was prescribed the antidepressant for major depressive disorder, and the MARs showed daily administration from August 2023 through September 2024. However, there was no documentation indicating that the resident was informed of the medication's risks and benefits, which was confirmed by the DNS and Regional Nurse Consultant.
A facility failed to ensure a safe system for a resident's self-administration of medication. A resident with multiple sclerosis, initially assessed to self-administer multiple medications but later only approved for Ventolin, was left with four unidentified medications unattended by an RN. A CNA also observed medications left at the resident's bedside. The DNS was informed, but no further information was provided.
A resident with Schizoaffective disorder was restricted from accessing their cell phone during nighttime hours, despite being cognitively intact and valuing personal belongings. Staff were unaware of the reason for this restriction, and no documentation justified it. The facility administrator acknowledged that residents should maintain their cell phones unless a behavior care plan states otherwise.
The facility failed to ensure continuous access to personal funds for two residents, both cognitively intact, with one having borderline personality disorder and the other schizoaffective disorder. Access was restricted to the presence of CFL staff, available only during specific hours. Staff confirmed the limitation, and the administrator acknowledged the issue, stating residents should have constant access to their funds.
The facility failed to maintain a homelike environment and adequate hot water temperatures in the main shower room. Residents reported inconsistent and cold water temperatures, confirmed by staff and maintenance tests. The shower room was also in disrepair, with missing baseboards, damaged walls, and a missing drain cover, posing safety risks.
The facility failed to complete PASARR Level II evaluations for two residents, risking their access to specialized services. One resident with Schizoaffective disorder and cerebral palsy did not receive a Level II evaluation for serious mental illness, while another resident with anxiety and depression did not receive a follow-up Level II evaluation after a significant change in condition. The Social Services Director acknowledged the oversight, and the Administrator provided no additional information.
The facility failed to update care plans for two residents, leading to discrepancies in assistive device usage and weight monitoring. One resident was observed without a mobility bar, contrary to the care plan, while another was found without specified bed rails and had conflicting weight monitoring instructions. Staff confirmed the care plans were not updated to reflect current needs.
A resident with dementia and depression did not receive an individualized activity program as per their preferences, such as listening to music and participating in group activities. The facility's activity logs showed minimal engagement, and staff were unaware of the resident's interests beyond music. The Activities Director admitted to limited one-on-one activities, and the administrator acknowledged the deficiency without further information.
A resident with a history of trauma and a diagnosis of borderline personality disorder did not receive trauma-informed care, as their clinical record lacked documentation of trauma assessment or identification of triggers. The Social Services Director confirmed that trauma screenings and care plans were standard practice, but no evidence was found for this resident. The facility administrator acknowledged the deficiency.
The facility failed to secure medication and treatment carts, leaving them unlocked and unattended on two occasions. The incidents were confirmed by the DNS and an LPN, violating the facility's policy that requires carts to be locked when not in use or attended by authorized personnel.
A resident with cognitive impairment and a history of stroke and kidney failure sustained skin tears during a transfer when CNAs failed to use a hoyer lift as required by the care plan. The incident highlights a lapse in following prescribed interventions for residents at risk of falls.
A resident with alcohol-induced dementia was physically abused by another resident with Lewy body dementia, who was known for agitation and aggression. The incident occurred when staff heard yelling and found the victim on the ground after being hit. Both residents later could not recall the event due to cognitive impairments.
A resident with Lewy body dementia, known for exit-seeking behavior and high fall risk, eloped from the facility by following a UPS driver. Despite wearing a Wanderguard, the resident exited onto a snow-covered sidewalk and fell, resulting in pain in the left hip and arm. Staff interviews confirmed the resident's frequent attempts to leave and the regular activation of the Wanderguard alarm, indicating inadequate supervision and a failure to maintain a safe environment.
Failure to Maintain Safe Food Storage Temperatures
Penalty
Summary
The facility failed to store foods at appropriate temperatures, leading to a deficiency in food safety. During an inspection, it was observed that a kitchen refrigerator was not maintaining the required temperature of 41 degrees F or less, as per the U.S. Food and Drug Administration's Food Code 2022. The refrigerator was found to be at 45 degrees F on the first inspection and 49 degrees F on a subsequent inspection. This refrigerator contained various food items, including uncooked meat, which were stored at unsafe temperatures. Staff 8, the Dietary Director, acknowledged the refrigerator had issues staying cool for a few weeks but did not take corrective action when informed of the temperature discrepancies. The Refrigerator Temperature Log for September 2024 showed multiple instances where the refrigerator temperature exceeded the acceptable range. Despite these recorded temperatures, no action was taken to address the issue. Staff 8 mentioned the possibility of the refrigerator door not closing properly and speculated that the Maintenance Director might have been notified, although no records of such notification were provided. The Maintenance Director confirmed he was not informed of the issue until the day of the inspection. The facility's failure to maintain proper food storage temperatures was identified as an immediate jeopardy situation, as raw meat stored at unsafe temperatures was planned to be used for an upcoming meal.
Removal Plan
- All food was removed from the refrigerator and disposed.
- The refrigerator was taken out of service.
- New foods would be purchased to serve to residents.
- All kitchen refrigerators would be checked for correct temperatures.
- The Administrator would educate the Dietary Manager and all dietary staff on the importance of refrigerator temperatures and action that should occur immediately with any food temperature concerns. Education would include storage, thawing, cooking and danger zone temperatures as well as when to dispose of any food that is in question. If dietary staff does not answer, they will be educated prior to their shift.
- The Administrator would educate maintenance on the importance of placing a malfunctioning refrigerator out of service and action that should occur immediately with any food temperature concerns.
- The Administrator or designee would audit refrigerator temperature logs daily for one week, then weekly for three weeks and then monthly for two months.
- The findings would be brought to QAPI to ensure substantial compliance is met.
- The Administrator would be responsible to ensure compliance.
Failure to Provide Accessible Contact Information for State Agencies and LTCO
Penalty
Summary
The facility failed to ensure that contact information for pertinent State agencies and the required Long Term Care Ombudsman (LTCO) poster were accessible to residents in one of the two units observed for required postings. This deficiency was identified during an observation on September 23, 2024, at 11:00 AM, where the necessary postings were found only in a hallway outside of the facility's locked enhanced care unit (ECU) and not inside the ECU itself. On September 25, 2024, at 3:30 PM, a resident expressed that they had no knowledge of where to access the contact information for pertinent State agencies or the LTCO and expressed interest in knowing this information. The resident also mentioned being unable to leave the ECU without a staff escort. On the same day at 10:55 AM, the facility's administrator acknowledged the findings and confirmed that ECU residents could not access the required postings without staff assistance.
Inadequate Sanitary Laundry Practices
Penalty
Summary
The facility failed to ensure sanitary laundry services for two of the six halls reviewed for infection control, placing residents at risk for cross-contamination. On two separate occasions, Staff 20, responsible for laundry services, was observed delivering clean resident clothing using a small, uncovered laundry cart throughout the 400 and 500 Halls. The cart was left unattended while Staff 20 delivered clothing from room to room. This practice was acknowledged by Staff 1, the Administrator, who confirmed that clean resident clothing should be covered during delivery.
Failure to Obtain Consent for Antidepressant Medication
Penalty
Summary
The facility failed to obtain consent before administering antidepressant medication to a resident, which was identified during an interview and record review. Resident 21, who was admitted in August 2023 with diagnoses including a fracture and dementia, was prescribed mirtazapine for major depressive disorder as per the physician's order dated August 25, 2023. The medication administration records (MARs) from August 2023 through September 2024 indicated that the resident received mirtazapine daily. However, a review of the resident's health record revealed no documentation showing that the resident was informed in advance about the risks and benefits of mirtazapine. On September 25, 2024, both the Director of Nursing Services (DNS) and the Regional Nurse Consultant confirmed the absence of documentation and acknowledged that consent was not obtained from the resident or their representative before starting the medication.
Failure in Safe Medication Self-Administration
Penalty
Summary
The facility failed to ensure a safe system for a resident's self-administration of medication, specifically for a resident diagnosed with multiple sclerosis who was cognitively intact. Initially, the resident was assessed to self-administer multiple medications but later was only approved to self-administer Ventolin. Despite this, a registered nurse left four unidentified medications at the resident's bedside unattended, believing the resident was assessed to take medications independently. This was corroborated by a CNA who observed medications left at the resident's bedside in the evenings. The Director of Nursing Services was informed of these observations, but no further information was provided by the time of the report.
Resident's Right to Retain Personal Possessions Violated
Penalty
Summary
The facility failed to ensure that a resident was allowed to retain personal possessions, specifically a cell phone, which is a violation of the resident's right to be treated with respect and dignity. The resident, who was admitted with a diagnosis of Schizoaffective disorder, was cognitively intact and expressed the importance of taking care of personal belongings. Despite this, the resident was restricted from having access to their cell phone during nighttime hours, from 7:00 PM to 9:00 AM, since admission. The resident expressed dissatisfaction with this restriction, feeling upset about not being able to contact their mother at will. Staff members, including CNAs and the Enhanced Care Unit Program Supervisor, were unaware of the specific reasons for the restriction, although there was a concern mentioned about the roommate potentially taking the phone. However, no documentation in the resident's clinical record justified the restriction. The facility administrator acknowledged the findings and stated that residents should be able to maintain their cell phones unless a behavior care plan indicated otherwise, which was not present in this case.
Deficiency in Resident Access to Personal Funds
Penalty
Summary
The facility failed to ensure that residents had continuous access to their personal funds, affecting two residents. Resident 1, who was admitted in October 2017 with a diagnosis of borderline personality disorder and was cognitively intact, reported being able to access their money only during daytime hours. Staff interviews revealed that access to funds was dependent on the availability of staff from the Center for Living (CFL), who were present from approximately 9:00 AM to 7:00 PM. Staff members, including CNAs and the Enhanced Care Unit Program Supervisor, confirmed that residents could not access their money outside these hours, and an LPN admitted to not knowing how to access resident funds when CFL staff were unavailable. Similarly, Resident 9, admitted in July 2024 with schizoaffective disorder and also cognitively intact, reported being unable to access funds after 7:00 PM on weekdays and after 4:00 PM on weekends. The same staff members reiterated that residents had to wait for CFL staff to access their money. The facility administrator acknowledged these findings, stating that residents should have access to their money at all times. This deficiency placed residents at risk of not having access to their personal funds when needed.
Inadequate Hot Water and Unhomelike Shower Room Conditions
Penalty
Summary
The facility failed to maintain a homelike environment and provide adequate hot water temperatures in the main shower room, affecting the residents' comfort and safety. Observations and interviews revealed that the water temperature in the shower room was inconsistent and often too cold. A resident reported that the water was too cold, while another mentioned that the water would fluctuate between hot and cold. A CNA confirmed the issue, stating that she had to start the shower early to allow the water to warm up. The maintenance director tested the water temperature, which was found to be 87 degrees Fahrenheit, despite the hot water heater gauge reading 99 degrees Fahrenheit. The administrator also tested the water, which reached only 94 degrees Fahrenheit. Additionally, the shower room was observed to be in a state of disrepair, contributing to an un-homelike environment. Sections of baseboard were missing, exposing unfinished and uncleanable sheetrock. The partition wall had significant damage, and the ceiling appeared torn and potentially water-damaged. The vent was dirty, the light bulb was exposed, and the drain cover was missing, leaving a three-inch hole in the floor that posed a potential injury risk. The administrator confirmed the damage and the inadequate water temperatures, acknowledging the un-homelike state of the shower room.
Failure to Complete PASARR Level II Evaluations
Penalty
Summary
The facility failed to ensure that a PASARR Level II evaluation was completed for two residents who required it, placing them at risk of not receiving specialized services. Resident 9, admitted with diagnoses including Schizoaffective disorder and cerebral palsy, had a PASARR Level I indicating indicators of both serious mental illness and a developmental disability. However, the PASARR Level II was only requested for the developmental disability, not the serious mental illness. The Social Services Director was unsure why the PASARR Level II for the serious mental illness was not completed, and the Administrator acknowledged the findings without providing additional information. Resident 26, admitted with anxiety and depression, initially had a PASARR Level I indicating no serious mental illness or developmental disability. However, a PASARR Level II was requested in 2023 due to an increase in paranoid delusions. After a hospitalization in 2024, Resident 26's new PASARR Level I indicated serious mental illness, but no additional PASARR Level II was requested to address this change. The Social Services Director admitted that an additional PASARR Level II should have been requested following the resident's significant change of condition, but it was not done. The Administrator was informed of these findings and did not provide further information.
Failure to Update Care Plans for Assistive Devices and Weight Monitoring
Penalty
Summary
The facility failed to ensure care plans were revised to accurately reflect the needs of two residents, leading to potential unmet needs. Resident 14, admitted with dementia and parkinsonism, was observed without a mobility bar on the bed, despite the care plan indicating its necessity for enhanced bed mobility. Staff confirmed that the care plan had not been updated to reflect the resident's current needs, as the mobility bar was no longer required. Similarly, Resident 35, admitted with delusional disorders, depression, and edema, was found without the bilateral 1/4 inch rails specified in the care plan. Staff confirmed that the resident did not use these devices, and the care plan had not been updated. Additionally, there was a discrepancy in the care plan regarding the frequency of weight monitoring for Resident 35, with the care plan indicating daily weights, while a physician's order specified weekly weights. Staff acknowledged the care plan had not been revised to align with the physician's order.
Failure to Provide Individualized Activity Program
Penalty
Summary
The facility failed to provide an ongoing program to support individual activity interests and preferences for a resident diagnosed with dementia and depression. The resident, admitted in January 2021, was noted to have short and long-term memory loss and was severely impaired in decision-making. The resident's activity preferences included listening to music, participating in group activities, and spending time outdoors. However, the facility's activity logs indicated that the resident only received four one-to-one activities and did not participate in any group activities over a month-long period. Observations revealed the resident was often in bed or in a wheelchair at the nurse's station or in their room, with no music playing, which was one of their known interests. Staff interviews revealed that the resident was non-verbal and unable to make choices about activities, with staff unaware of any interests outside of music. The Activities Director admitted to not engaging in many one-on-one activities with the resident and was unable to specify the resident's favorite activities beyond listening to music. Despite attempting a sensory mat once, no further sensory activities were tried. The facility's administrator acknowledged the findings but did not provide additional information, indicating a lack of adherence to the facility's policy of assessing and addressing residents' activity preferences and needs.
Failure to Provide Trauma-Informed Care for a Resident
Penalty
Summary
The facility failed to provide trauma-informed care to a resident who was a trauma survivor, as evidenced by the lack of documentation and assessment of the resident's past trauma and potential triggers for re-traumatization. The resident, admitted in October 2017, had a diagnosis of borderline personality disorder and reported a history of childhood and teenage abuse. Despite being cognitively intact, the resident's clinical record did not reflect any assessment or identification of trauma history or triggers. During interviews, the Social Services Director acknowledged that residents were screened for trauma and care plans were developed for those who experienced trauma, including identifying possible triggers. However, there was no documentation indicating that the resident in question was ever screened for trauma. The facility administrator confirmed the findings of the investigation but did not provide any additional information.
Medication and Biologicals Security Lapse
Penalty
Summary
The facility failed to ensure that medications and biologicals were secured and accessible only to authorized personnel, as observed during a survey. On two separate occasions, medication and treatment carts were found unlocked and unattended. The first incident occurred on the 300 hall, where a treatment cart was left unlocked and unattended, confirmed by the Director of Nursing Services (DNS). The second incident took place on the 500 hall, where a medication cart was similarly left unlocked and unattended, confirmed by a Licensed Practical Nurse (LPN). The facility's Medication Storage Policy mandates that medication carts should remain locked when not in use or attended by authorized personnel, which was not adhered to in these instances.
Failure to Follow Care Plan Results in Resident Injury
Penalty
Summary
The facility failed to adhere to the care plan interventions for a resident who was at risk for falls due to muscle weakness. The resident, who was moderately impaired in cognition and had a history of stroke and kidney failure, was supposed to be transferred using a two-person hoyer lift. However, during a transfer from bed to wheelchair, the care plan was not followed, resulting in the resident sustaining two skin tears on the right forearm. The incident occurred when two CNAs, unfamiliar with the resident, attempted the transfer without using the hoyer lift as required. The skin tears were assessed and cleaned by an RN, measuring 1.5 cm each and horseshoe-shaped. The Director of Nursing Services confirmed that the care plan was not followed, emphasizing that the expectation was for care plans to be adhered to at all times.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident. Resident 101, who was cognitively intact, was admitted with alcohol-induced dementia. Resident 100, admitted with Lewy body dementia, was severely cognitively impaired and had a history of agitation and aggression. On the day of the incident, staff heard yelling and cursing from the shared room of Residents 100 and 101. Upon entering, staff observed Resident 101 on the ground and Resident 100 standing over them, having hit Resident 101 in the face over a misunderstanding about personal belongings. Staff interviews revealed that Resident 100 could be pleasant but also verbally aggressive, and had previously been instructed to intervene to protect others' safety. After the altercation, Resident 101 was initially scared but later could not recall the incident due to poor short-term memory. Resident 100 also could not remember the details of the event. The facility's failure to prevent this altercation placed residents at risk for abuse.
Failure to Prevent Elopement and Fall of a Resident with Dementia
Penalty
Summary
The facility failed to ensure adequate supervision and a safe environment for a resident with Lewy body dementia, who was at high risk for elopement and falls. The resident, admitted in July 2021, was known to exhibit exit-seeking behaviors and was equipped with a Wanderguard to monitor such tendencies. Despite these precautions, the resident frequently attempted to leave the facility, as noted in care plans and assessments. On November 30, 2022, the resident followed a UPS driver out of the facility, stepping onto a snow-covered sidewalk and subsequently falling, resulting in pain in the left hip and arm. Interviews with staff revealed that the resident consistently lingered near the facility's doors, often asking to go outside. Staff acknowledged the resident's persistent exit-seeking behavior and the frequent activation of the Wanderguard alarm. On the day of the incident, the weather conditions included snow and ice, which contributed to the resident's fall after exiting the facility. The incident highlights the facility's failure to provide adequate supervision and maintain a safe environment for the resident, who was at high risk for elopement and falls.
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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