Independence Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Independence, Oregon.
- Location
- 1525 Monmouth Street, Independence, Oregon 97351
- CMS Provider Number
- 385188
- Inspections on file
- 20
- Latest survey
- February 18, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Independence Health & Rehabilitation Center during CMS and state inspections, most recent first.
Two residents experienced falls due to staff not following care plans requiring two-person assistance for transfers. One resident, with dementia and hemiplegia, fell and fractured their femoral neck when a CNA attempted to assist alone. Another resident, post-stroke and at risk for falls, was transferred by a CNA without reviewing the care plan, resulting in a fall without injury. Both incidents highlight a failure to adhere to care plans, risking resident safety.
The facility failed to maintain a homelike environment, with issues such as exposed drywall, loud bathroom fans, and a cold shower room affecting residents. A resident's room had unpainted drywall due to water damage, while others experienced loud fan noises. The shower room was cold due to an incorrectly installed fan. Staff acknowledged these issues, but they remained unresolved, impacting residents' comfort.
A facility failed to obtain and implement PASARR findings for a resident with mental health issues and visual impairment. Despite a PASRR Level II evaluation recommending increased medication and psychiatric referral, the facility did not receive a revised evaluation and failed to follow up, resulting in the resident not receiving necessary mental health resources.
A resident with a stroke diagnosis did not receive a restorative program as recommended by OT to maintain and improve ROM. Despite a referral for exercises and a hand splint, staff did not implement the program, leading to decreased ROM. Interviews and observations confirmed the lack of intervention.
A resident with heart disease was prescribed multiple blood-thinning medications, and pharmacy recommendations to evaluate and potentially discontinue some were not acted upon timely by the physician. Additionally, recommendations for a gradual dose reduction of sertraline were not addressed, with staff acknowledging delays in physician response.
A resident with a cerebral hemorrhage experienced consistent loose stools and expressed concerns about bowel incontinence. Despite reporting these issues to CNAs, the resident's bowel movements remained mostly soft or loose over 30 days. The resident was on a laxative medication, Senna-Docusate Sodium, for constipation. The DNS expected CNAs to report concerns to the charge nurse, who should then inform the practitioner to adjust medications during weekly visits.
Two residents were found without working call systems in their bathrooms, posing a risk for inability to call for assistance. One resident with heart failure and cognitive impairment, and another with diabetes, both required assistance for bathroom transfers. The Maintenance Director confirmed the absence of call light cords, and the issue was not reported in the maintenance log. The Administrator was aware but did not replace the cords until two days later.
A resident with a leg wound experienced worsening conditions due to the facility's failure to provide adequate care. The wound, initially managed with a vacuum, was not consistently assessed or documented as per the facility's policy. A physician's order for wound care was not entered into the TAR, and there was a lack of documentation for care on specific dates. The resident's wound became necrotic and infected, leading to sepsis and the need for debridement. Staff interviews revealed inconsistencies in wound care practices and a lack of treatment supplies.
A resident with chronic pain conditions experienced inadequate pain management due to delays in receiving PRN medications and lack of necessary wound care supplies. Despite frequent complaints, the facility staff failed to address the issue, leading to increased pain levels and affected daily activities.
Failure to Follow Care Plans Leads to Resident Falls
Penalty
Summary
The facility failed to ensure that two residents were transferred according to their care plans, leading to falls and potential injury. Resident 2, who was non-verbal and diagnosed with dementia and hemiplegia following a stroke, required the assistance of two caregivers for personal care. However, a former agency CNA did not review the care plan and attempted to assist the resident alone, resulting in a fall and a fracture of the right femoral neck. The CNA admitted to not being aware of the care plan requirements, and the LPN on duty confirmed that assistance was readily available if requested. Similarly, Resident 31, who had a history of stroke and was at risk for falls, required two-person assistance for transfers. Despite this, an agency CNA attempted to transfer the resident alone after the resident insisted they only needed one person. The CNA did not review the care plan before the transfer, leading to the resident becoming weak and being eased to the floor, though no injury occurred. The DNS verified that the resident was not transferred as care planned, resulting in a fall.
Facility Fails to Maintain Homelike Environment Due to Disrepair and Noise
Penalty
Summary
The facility failed to maintain a homelike environment for its residents, as evidenced by several instances of disrepair and noise disturbances. Resident 35's room had an unpainted area with exposed drywall behind the headboard, which had been in disrepair for a while. Staff 17, a CNA, acknowledged the issue, and the Maintenance Director, Staff 12, confirmed that the wall had been down for two months due to ongoing water damage. Similarly, Resident 31's bathroom had a cut, unpatched, and unpainted drywall area behind the toilet, which Staff 12 admitted had not been repaired despite frequent leaks. Several residents, including Residents 20, 38, and 19, experienced loud, metal rattling noises from bathroom fans when activated. Resident 20, who was cognitively impaired, stated the fan had been loud for years, and Staff 12 verified the noise. Resident 38, with moderate cognitive impairment, also reported the fan noise, and the drywall behind the toilet was similarly cut and unpatched. Staff 1, the Administrator, was not notified by residents or staff about the noisy fans, contributing to an unhomelike environment. Additionally, the [NAME] Hall shower room was consistently cold, with cold air being pushed down from the ceiling when the fan was activated. Staff 14, a CNA, reported the issue to Staff 12, who later identified that the fan was installed incorrectly. Resident 11, who was cognitively intact, confirmed the cold air issue and stated they had to be transported to another hall for showers. Staff 1 acknowledged the need for prompt drywall repairs to ensure a quality living environment, but these issues remained unresolved, leading to an uncomfortable and unhomelike environment for the residents.
Failure to Implement PASARR Recommendations for Resident
Penalty
Summary
The facility failed to obtain and implement the PASARR (Preadmission Screening and Resident Review) findings in a timely manner for a resident with mental health diagnoses and a serious visual impairment. The resident was admitted in September 2020 and had a PASRR Level II evaluation in February 2024, which indicated the need for a mental health evaluation to be completed within 14 days. The evaluation revealed the resident was at risk for self-endangerment, heard voices, and was agoraphobic. Recommendations included increasing the resident's antipsychotic medication, referring to a psychiatric prescriber for medication management, and exploring resources for the visually impaired. However, the facility did not receive a revised copy of the evaluation after requesting it due to incorrect information in the initial report. Interviews with facility staff revealed that the PASARR assessments were typically sent to the facility within a month after completion, but the facility did not notify the evaluator that they had not received the results. The staff responsible for receiving and reviewing the PASARR assessments did not follow up adequately to ensure the recommendations were implemented. Consequently, the interdisciplinary team did not review the recommendations, and the resident's care plan was not updated to include the suggested interventions. This oversight placed the resident at risk for inadequate mental health resources and support.
Failure to Implement Restorative Program for Resident
Penalty
Summary
The facility failed to ensure a resident received a restorative program as recommended by occupational therapy (OT) for maintaining and improving range of motion (ROM). The resident, who was admitted in July 2023 with a diagnosis of stroke, was discharged from skilled therapy with instructions for staff to assist in maintaining strength, endurance, and improving ROM. This included the use of a resting hand splint and exercises with elastic bands and weights. However, there was no evidence in the resident's records that the restorative program was implemented as per the OT's referral from July 2024. Interviews with staff confirmed that the program was not carried out, and the resident reported decreased ROM and lack of assistance with ROM exercises. Observations also noted the absence of the prescribed splint.
Failure to Act on Pharmacy Recommendations for Medication Management
Penalty
Summary
The facility failed to ensure timely action on pharmacy recommendations for a resident with heart disease, who was prescribed multiple blood-thinning medications: Eliquis, clopidogrel, and cilostazol. Pharmacy recommendations were made on three separate occasions to evaluate the concurrent use of these medications and consider discontinuing clopidogrel and cilostazol. However, there was no documented response from the resident's physician for the first two recommendations, and the third recommendation was only referred to a cardiologist without further action. Staff interviews revealed that the facility disbursed the recommendations to the appropriate physicians, but there was no explanation for the lack of timely response. Additionally, the resident was prescribed sertraline, an antidepressant, and pharmacy recommendations were made for a gradual dose reduction (GDR) or a rationale for not implementing a GDR. Despite multiple requests, there was no response documented in the resident's clinical record. Staff acknowledged that the resident's outside physician did not respond to requests in a timely manner, requiring up to four requests for a single recommendation. This inaction placed the resident at risk for an adverse medication regimen.
Failure to Monitor and Adjust Medication for Resident with Loose Stools
Penalty
Summary
The facility failed to ensure appropriate monitoring and dosing of medications for a resident admitted with a diagnosis of cerebral hemorrhage. The resident experienced consistent loose stools and expressed concerns about bowel incontinence to CNAs and an LN, although the resident could not recall specific staff members. A CNA confirmed the resident's consistent soft or loose bowel movements and reported these concerns to the charge nurse multiple times. Despite this, the resident's bowel care task record showed only one normal bowel movement in the past 30 days, with the rest documented as soft or loose. The resident had a physician's order for Senna-Docusate Sodium, a laxative, to be administered twice daily for constipation. The DNS stated that CNAs should inform the charge nurse of any concerns, and the charge nurse should review the record and inform the practitioner, who should adjust medications as needed during weekly visits.
Failure to Provide Working Call Systems in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that a working call system was available in the bathrooms of two residents, placing them at risk for the inability to call for assistance. Resident 20, who was admitted in August 2020 with a diagnosis of heart failure and was cognitively impaired, was observed without an emergency call light cord in their bathroom. Despite being monitored for self-transfers to the bathroom, the call light cord was missing from 2/9/25 and was not replaced until 2/11/25. Staff 12, the Maintenance Director, confirmed the absence of the call light cord, and Staff 13, the Maintenance Assistant, noted that the issue was not reported in the maintenance log. Similarly, Resident 9, admitted in 2019 with diabetes, also lacked an emergency call device in their bathroom. The care plan indicated that Resident 9 required assistance for bathroom transfers and should not be left alone. The absence of the call light cord was verified by Staff 12, and Staff 13 confirmed that the need for replacement was not logged. The Administrator was aware of the missing call light cords for both residents but did not ensure their replacement until two days after the issue was identified.
Failure to Provide Adequate Wound Care
Penalty
Summary
The facility failed to provide adequate care and services for a resident with a non-pressure skin wound, leading to a deficiency. The resident was admitted with a contusion and an open wound on the right lower leg, which was managed with a wound vacuum. However, the facility did not consistently document or assess the wound as required by their Skin Integrity policy. The resident's care plan included monitoring and documenting the wound's condition, but there was no evidence of weekly assessments for size, color, odor, exudates, or pain. Additionally, a physician's order for wound care was not entered into the Treatment Administration Record (TAR), and there was a lack of documentation indicating that wound care was completed on specific dates. The resident's condition worsened, with the wound becoming necrotic and infected, leading to sepsis and the need for debridement. The resident reported increased pain when the wound vacuum was removed, and the facility staff failed to maintain adequate wound treatment supplies. Staff interviews revealed inconsistencies in wound care practices, with some staff unable to recall if care was provided and others indicating that assessments were not consistently performed. The facility's failure to adhere to its own protocols and physician orders contributed to the deterioration of the resident's wound condition.
Inadequate Pain Management for Resident with Chronic Pain
Penalty
Summary
The facility failed to provide appropriate and timely pain management for a resident with chronic pain conditions, including fibromyalgia, polyneuropathy, arthritis, and an open wound. The resident was admitted in May 2024 and was on a pain medication therapy plan that required staff to administer medications as ordered, review pain medication efficacy every shift, and respond to any complaints of pain. However, the resident frequently experienced delays in receiving PRN pain medications, sometimes waiting two to three hours, which led to increased pain levels and affected their daily activities. In August and September 2024, the resident's pain management was inconsistent, with documented pain levels ranging from four to ten on a zero to ten scale. The resident reported that medications were not delivered timely, and there were instances where the facility did not have the necessary lidocaine for wound pain management. Staff interviews confirmed that the resident often complained about not receiving PRN pain medications promptly, and there were issues with a specific CMA being confrontational and delaying medication administration. Despite being aware of the resident's complaints, the facility administration and nursing staff did not take adequate steps to address the issue. A former LPN confirmed the absence of lidocaine on a specific date, and a CNA reported frequent complaints from the resident about delayed medication. The facility administrator and DNS were unaware of the resident's concerns, indicating a lack of communication and oversight in ensuring timely pain management for the resident.
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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