La Grande Post Acute Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in La Grande, Oregon.
- Location
- 91 Aries Lane, La Grande, Oregon 97850
- CMS Provider Number
- 385211
- Inspections on file
- 18
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at La Grande Post Acute Rehab during CMS and state inspections, most recent first.
A resident with an indwelling urethral catheter had a physician order for an 18 Fr Foley catheter to be changed on a scheduled basis. On one shift, an RN changed the catheter but used a 20 Fr catheter because the ordered size was not available and did not notify the provider or facility leadership of this change. Later that evening, another RN was called due to the resident’s discomfort and, upon reassessment and lack of urine output despite fluid intake, discovered the catheter was a larger size than ordered, confirming that the catheter change had not followed the physician’s order or professional standards of care.
A resident with a known history of inappropriate touching was left unsupervised in the dining hall when a CNA briefly left to assist another resident. During this time, the resident touched another cognitively intact resident's genital area over clothing, despite verbal objections. The incident was witnessed by another resident, who called for help, and staff responded after hearing yelling. The lack of staff presence and supervision allowed the incident to occur.
A resident with a history of disinhibited sexual behaviors and a care plan requiring line-of-sight supervision was left unsupervised in the dining room by a CNA, resulting in the resident inappropriately touching another resident. Staff were aware of the resident's behavioral history and the need for supervision, but the care plan was not followed.
The facility failed to maintain hygienic conditions in its walk-in freezer and dry storage rooms, risking food-borne illness and cross-contamination. Observations included discarded food items on the floor, improperly stored food cartons, and unsealed food containers. The Dietary Manager acknowledged these issues, and the Administrator expected sanitary food storage practices.
A facility failed to reconcile controlled drugs accurately, as Morphine was found in a medication cart without a physician order or documentation in the accountability record. A CMA and a state surveyor discovered the issue, and the DNS confirmed the lapse in protocol for tracking and reconciling controlled substances.
A facility failed to secure a treatment cart and maintain proper medication refrigerator temperatures. The cart, left unlocked and unattended, contained various medications accessible to unauthorized individuals. The refrigerator lacked a thermometer, leading to temperature fluctuations that compromised drug efficacy. The pharmacist confirmed the need to destroy affected medications.
The facility failed to inform two residents of the risks and benefits of their prescribed psychotropic medications. One resident, with anxiety, was not informed about Duloxetine until months after administration began. Another resident, with Alzheimer's and bipolar disorder, was not informed about lurasidone and escitalopram. Staff confirmed these oversights.
A resident's wheelchair arm rests were found to be in disrepair, with torn and cracked surfaces exposing uncleanable cloth foam. The facility's maintenance log showed no reports of this issue, despite staff being instructed to document such concerns. Both the CNA and Maintenance Director confirmed the lack of documentation, and the Executive Director acknowledged the poor condition of the wheelchair arm rests.
A facility failed to follow bowel care physician orders for a resident, leading to multiple instances of unaddressed constipation. Despite the facility's Bowel Protocol Policy requiring action after three days without a bowel movement, the resident's records showed no PRN medications were administered during several periods of constipation. The resident, who was cognitively intact, reported experiencing long periods without a bowel movement, and the Divisional Director of Clinical Operations confirmed the protocol was not followed.
The facility did not have an antibiotic stewardship program in place, as confirmed by the Divisional Director of Clinical Operations. Four residents were receiving antibiotics without verified appropriate monitoring. Key staff, including the Infection Preventionist and Medical Director, were not conducting the required monthly reviews of antibiotic use.
Incorrect Foley Catheter Size Used and Physician Order Not Followed
Penalty
Summary
The deficiency involves failure to provide catheter care and treatment in accordance with professional standards for a resident with an indwelling urethral catheter. The resident was admitted with an order for an 18 French Foley catheter to be changed every four weeks. On one evening, a registered nurse documented changing the resident’s Foley catheter, and later that same evening, the resident requested that another registered nurse flush the catheter. When the second nurse rechecked the resident a couple of hours later, there was no urine output despite the resident having consumed over 400 cc of water. Upon assessment, the second nurse observed that the catheter in place was a size 20 French, not the ordered 18 French. The second nurse later stated that when she attempted to adjust the catheter due to the resident’s discomfort, she noticed the catheter was larger than ordered. The nurse who performed the catheter change acknowledged she had used a 20 French catheter because she could not find an 18 French in the facility and did not notify anyone at the facility or the provider about this deviation from the physician’s order. The Director of Nursing Services confirmed that physician orders should be followed and acknowledged that the wrong catheter size had been used for this resident.
Failure to Prevent Sexual Abuse Due to Lack of Supervision
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse when one resident was observed touching another resident's genital area over clothing in the dining hall. Both residents involved were cognitively intact, as indicated by their BIMS scores. The incident occurred when a CNA, who was aware of the perpetrating resident's history of inappropriate touching, left the dining room briefly to assist another resident. During this absence, the resident with a history of inappropriate behavior approached and touched the other resident, despite the latter's verbal objections. The incident was witnessed by another resident, who called for help, prompting staff to intervene. At the time of the incident, there were no staff present in the dining room, leaving the residents unsupervised. Staff interviews confirmed that the CNA assigned to supervise had left the area, and other staff only became aware of the situation after hearing yelling. The lack of supervision allowed the incident to occur, and the facility's failure to ensure continuous monitoring of a resident with known behavioral risks directly led to the deficiency.
Failure to Implement Supervision Care Plan for Resident with Inappropriate Sexual Behaviors
Penalty
Summary
The facility failed to implement the care plan for a resident with a history of disinhibited sexual behaviors, specifically related to inappropriate touching of other residents. The resident, who was cognitively intact and had a care plan revised to address these behaviors, was to be kept within line of sight of staff and not allowed to dine with residents of the opposite gender. Despite these interventions, a certified nursing assistant (CNA) left the resident unsupervised in the dining room while attending to another resident, during which time the resident in question inappropriately touched another resident. Staff interviews confirmed awareness of the resident's behavioral history and the lapse in supervision that allowed the incident to occur.
Improper Food Storage and Hygiene in Kitchen
Penalty
Summary
The facility failed to maintain hygienic conditions in its walk-in freezer and dry storage rooms, which placed residents at risk of food-borne illness and cross-contamination. During an initial tour of the kitchen, surveyors observed several issues in the walk-in freezer, including a discarded frozen snack cup and a partial hamburger patty on the floor, a cardboard case of chocolate health shake cartons stored on the floor, and discarded plastic wrappers scattered under and between shelving units. Additionally, a plastic-lined cardboard case of frozen peas and chopped carrots was found with the lid unsealed and open. In the dry-storage room, a plastic-lined cardboard box of parboiled rice was also found with the lid unsealed and open. The Dietary Manager acknowledged that the food in the freezer was not stored properly and that the freezer was not cleaned appropriately. During a follow-up tour, a cardboard box of saltine crackers was observed stored on the floor of the food storage closet adjacent to the rear kitchen door. The Dietary Manager confirmed that no food items should be stored on the floor, even if they were in boxes. The facility's Food Storage policy requires that food storage areas be kept clean at all times, dry bulk foods be stored in seamless plastic or metal bins with tight-fitting lids, and items in the freezer be kept on shelving above the floor. The Administrator stated that he expected food to be stored in a sanitary manner with residents' safety in mind.
Failure to Reconcile Controlled Drugs
Penalty
Summary
The facility failed to ensure accurate reconciliation and accountability for controlled drugs, specifically Morphine, in one of the medication carts reviewed. During an inspection, it was discovered that the narcotic compartment of the medication cart contained four bubble pack cards of Morphine, each with 60 half tablets, labeled with a resident's name. However, there was no physician order for Morphine for this resident, and the medication was not documented in the facility's accountability record. This oversight was identified during a review by a Certified Medication Aide (CMA) and a state surveyor. Staff 5, the CMA, acknowledged the absence of documentation and reported the issue to the Director of Nursing Services (DNS) and other agency nurses, awaiting further instructions. Staff 2, the DNS, confirmed that the proper procedure was to document controlled drugs immediately upon receipt and to reconcile them at each shift change. However, the DNS was unaware of the Morphine's presence in the narcotic compartment until the surveyor's review, indicating a lapse in the facility's protocol for tracking and reconciling controlled substances.
Medication Security and Storage Deficiencies
Penalty
Summary
The facility failed to ensure the security and proper storage of drugs and biologicals, as evidenced by an unlocked and unattended treatment cart and improper temperature control in the medication refrigerator. On one occasion, a treatment cart located near the nursing station was left unlocked and unattended by two nursing students, making it accessible to unauthorized staff and residents. The cart contained various medications, including insulin and medicated creams, which should have been secured when not in use. The facility's policy required that treatment carts be locked when unattended, a standard that was not adhered to in this instance. Additionally, the medication refrigerator was found to be improperly monitored and maintained, with no thermometer inside to track temperatures. A CMA was observed using a thermometer from an adjacent empty refrigerator to check the temperature, which was found to be significantly below the recommended range. The refrigerator's temperature fluctuated between 20 degrees F and 50 degrees F, compromising the efficacy of the stored medications, including insulin, vaccines, and other critical drugs. The facility's policy and CDC guidelines specify that medications requiring refrigeration should be stored between 36 degrees F and 46 degrees F, a standard that was not met. The pharmacist confirmed that the fluctuating and potentially freezing temperatures compromised the refrigerated drugs, necessitating their removal and destruction. The facility's failure to maintain proper storage conditions for medications and biologicals placed residents at risk for receiving ineffective treatments. The administrator and divisional director of clinical operations were informed of these findings, acknowledging the deficiencies in medication security and storage practices.
Failure to Inform Residents of Psychotropic Medication Risks and Benefits
Penalty
Summary
The facility failed to inform two residents of the risks and benefits associated with their prescribed psychotropic medications. Resident 10, admitted in May 2024 with a diagnosis of anxiety, was prescribed Duloxetine, an antianxiety medication, but was not informed of its risks and benefits until October 2024, despite having been administered the medication since May 2024. Staff 3, a Registered Nurse and Divisional Director of Clinical Operations, confirmed this oversight. Similarly, Resident 7, who was admitted in October 2021 with Alzheimer's disease and bipolar disorder, was prescribed lurasidone, an antipsychotic, and escitalopram, an antidepressant, in February 2025. However, there was no documentation indicating that Resident 7 was informed of the risks and benefits of these medications. Staff 2, the Director of Nursing Services, acknowledged that Resident 7 was not informed in advance.
Failure to Maintain Safe and Clean Wheelchair Arm Rests
Penalty
Summary
The facility failed to provide a safe and clean environment for a resident by not maintaining the resident's wheelchair arm rests in proper condition. On February 10, 2025, it was observed that the left arm rest of the resident's wheelchair was torn and cracked, exposing uncleanable cloth foam. This condition was not reported in the facility's maintenance log, which covered the period from December 5, 2024, to February 10, 2025. Staff members, including a CNA and the Maintenance Director, confirmed that the procedure was to document such issues in the maintenance log, but no reports were made regarding the resident's wheelchair. The Executive Director also confirmed the poor condition of the wheelchair arm rests and acknowledged the expectation for residents to have safe and cleanable wheelchairs.
Failure to Administer Bowel Care Medications as Ordered
Penalty
Summary
The facility failed to adhere to the bowel care physician orders for a resident who was admitted with a diagnosis including pain. The facility's Bowel Protocol Policy, updated in 2018, required that each resident be placed on a daily bowel monitoring program, with licensed nurses reviewing the bowel monitoring daily. If a resident did not have a bowel movement for three days, the nurse was to administer the physician-ordered bowel program or the facility-specific PRN medication bowel program. However, the resident's bowel records from January 10 to January 31 revealed multiple instances where the resident did not have a bowel movement for several consecutive days, specifically on the 16th, 17th, 18th, 19th, 20th, 24th, 25th, 26th, 27th, and 28th. Despite the absence of bowel movements on these dates, the Medication Administration Record (MAR) showed that no PRN bowel care medications for constipation were administered. The resident, who was cognitively intact, expressed experiencing long periods without a bowel movement and noted that staff had not addressed the constipation. The Divisional Director of Clinical Operations confirmed that the PRN medications were not administered according to the facility protocol for bowel care, acknowledging that the protocol should have been followed.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program, which is a critical component of infection control. During the review, it was found that there was no evidence of such a program in place. Staff 3, the Divisional Director of Clinical Operations, was interviewed and confirmed the absence of an antibiotic stewardship program. Staff 3 also mentioned that four current residents were receiving antibiotics, but there was no verification of appropriate monitoring for the continued use of these medications. Furthermore, Staff 3 indicated that key personnel, including the Infection Preventionist, Pharmacist, Executive Director, and Medical Director, were supposed to be involved in a monthly review of antibiotic use, but these meetings had not been conducted.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
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.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
