Laurel Hill Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Grants Pass, Oregon.
- Location
- 859 Ne 6th Street, Grants Pass, Oregon 97526
- CMS Provider Number
- 385232
- Inspections on file
- 19
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Laurel Hill Nursing Center during CMS and state inspections, most recent first.
A resident with a Stage 4 sacral pressure ulcer and intact cognition returned from a wound clinic with an order from an NP for wheelchair seat mapping to obtain a new cushion after a prior Roho cushion had been removed. Facility staff documented the order and faxed it to a vendor, but the fax was sent to an incorrect number, and the seat mapping was neither timely ordered nor completed. Follow-up notes showed that when staff later contacted the vendor, the vendor reported not receiving the fax and requested the order again, leading to prolonged delays in scheduling the seat mapping and failure to carry out the physician’s wound care-related order.
The facility failed to follow proper dish sanitation practices, risking foodborne illnesses. The dish machine required a chlorine rinse concentration of 50 ppm, but Staff 26 did not know how to test chemical levels and inaccurately recorded them based on trends. Staff 27 confirmed the log's inaccuracy, and leadership acknowledged the need for consistent testing.
The facility failed to timely report allegations of abuse and altercations involving three residents with cognitive impairments. Incidents involving inappropriate touching and verbal altercations were reported to the State Survey Agency 16 days late, contrary to facility policy. Staff awareness did not translate into prompt reporting, leading to delayed Facility Reported Incident submissions.
A resident with chronic pain was found with two fentanyl patches, indicating a failure to remove the old patch before applying a new one. This error was discovered during a medication error investigation, revealing a lapse in the administration process for pain management.
A resident with dementia and depression was verbally abused by another resident with delusional disorders. Despite staff awareness, the incident was not reported or documented as abuse, and the behavior was dismissed as normal. The facility failed to adhere to its policy to prevent and investigate abuse, placing residents at risk.
A resident developed a new pressure ulcer that was identified by a CNA but not assessed by a nurse until the following day, leading to delayed treatment. Communication lapses among staff contributed to the oversight, as the assigned LPN was not informed, and the wound nurse assessed the ulcer only after being notified the next day.
A resident with atrial fibrillation and high blood pressure received hydralazine despite having systolic blood pressures below the prescribed threshold. The MAR required holding the medication if the systolic pressure was less than 120, but it was administered multiple times with readings below this level. Staff, including an RN and an LPN, acknowledged the error, and the DNS confirmed the failure to follow physician orders.
A resident with a stroke diagnosis and identified dental issues, including likely cavities and broken molars, did not receive necessary dental services. Despite the MDS indicating these issues, the care conference failed to address the need for a dental assessment. Staff interviews revealed that the resident's representative was not contacted to offer dental services, and a dental referral was not made as required.
The facility failed to prevent cross-contamination by storing clean items, including pillows and cushions, on the dirty side of the laundry room. Staff responsible for laundry and housekeeping reported the issue to the maintenance director, but the items remained for about a month. The Assistant Maintenance Director admitted to placing the items there, unaware of the infection control issue. The Administrator and DNS were informed and acknowledged the concern.
The facility failed to thoroughly investigate allegations of abuse and injuries for three residents. A resident with severe cognitive impairment was found with a bruise, but witness statements were not collected from all involved staff. In another case, an alleged inappropriate touching incident was not properly documented, lacking critical details and witness information. The administration acknowledged the failure to conduct comprehensive investigations, placing residents at risk.
The facility failed to follow physician orders and medication protocols for four residents, leading to unmet care needs. A resident with a stroke did not receive bowel care medication as ordered, while another with a history of falls did not have required neuro checks documented after an unwitnessed fall. A hospice patient was given nitroglycerin without notifying hospice, and a resident with chronic pancreatitis did not receive necessary medication due to the facility's failure to obtain it.
Failure to Follow Physician Orders for Wheelchair Seat Mapping for Pressure Ulcer Management
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for wound care interventions for one cognitively intact resident with a Stage 4 sacral pressure ulcer and a history of stroke. The resident was evaluated in a wound ostomy clinic, where the nurse practitioner documented that the resident’s wound healing had stalled and ordered a wheelchair seat mapping to obtain an appropriate new wheelchair cushion after a previously ordered Roho cushion had been removed from use. The order specified that the facility should schedule the seat mapping appointment, and a progress note documented that the resident returned from wound care with this new order related to the sacral pressure injury. The order was faxed to a vendor the same day. Despite this, subsequent documentation showed that the seat mapping was not timely ordered or completed. Two days after the order, the nurse practitioner confirmed that the seat mapping had still not been ordered or completed. Weeks later, a nurse’s progress note indicated that when staff called the vendor for an update, the vendor reported they needed the order faxed, and a later note documented that the vendor had not received any faxes from the facility. It was confirmed that the facility had faxed the order to an incorrect fax number. Additional information from the DNS indicated that the referral had to be re-faxed months later and that there were ongoing unsuccessful attempts at communication with the vendor, resulting in a significant delay between the original order and the scheduling of the seat mapping appointment. This sequence of events reflects the facility’s failure to ensure timely and accurate coordination and follow-through on the physician’s order for wheelchair seat mapping for the resident’s pressure ulcer management.
Failure to Follow Dish Sanitation Practices
Penalty
Summary
The facility failed to properly follow dish sanitation practices in the kitchen, which placed residents at risk for foodborne illnesses. The dish machine required a chlorine rinse concentration of 50 parts per million to sanitize dishes. However, Staff 26, who was responsible for operating the dish machine, did not know how to test the chemical levels. Despite this, Staff 26 recorded the chemical concentration as adequate on the Dish Machine log for multiple shifts by using the documented trends of other staff, rather than actual testing. Staff 27, the Dietary Manager, acknowledged that the Dish Machine log was inaccurate and that the facility did not verify proper chemical levels during each shift. This was further confirmed by Staff 1, the Administrator, Staff 2, the DNS, and Staff 12, the Regional Director of Clinical Operations, who acknowledged the need for consistent testing of chemical levels using test strips to ensure proper dish sanitation.
Delayed Reporting of Abuse and Altercations
Penalty
Summary
The facility failed to report allegations of abuse to the State Survey Agency in a timely manner for three residents. Resident 7, who had dementia and mild cognitive impairment, was involved in an incident where it was reported that they inappropriately touched another resident. The facility became aware of this allegation on November 24, 2024, but did not report it until December 9, 2024, which was 16 days later. Similarly, Resident 19, who had severe cognitive impairment due to a stroke, was reportedly touched inappropriately by another resident on the same date, and this incident was also reported 16 days late. Staff members involved in these incidents failed to report them promptly, and the facility administrator acknowledged the delay in reporting. Additionally, an altercation occurred between Resident 12, who had dementia and depression, and Resident 20, who had delusional disorders and mild cognitive impairment. Resident 12 reported feeling uncomfortable and intimidated after Resident 20 yelled and cussed at them during dinner. Despite staff being aware of the incident, it was not reported to the administration or the State Survey Agency in a timely manner. The facility's policy required documentation and investigation of such incidents to protect residents, but this was not adhered to, resulting in a delayed Facility Reported Incident submission.
Medication Error in Fentanyl Patch Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically related to the administration of fentanyl patches. A resident, who was admitted with diagnoses including prostate cancer, UTI, and chronic pain, was prescribed a fentanyl transdermal patch to be applied every three days. However, on one occasion, two patches were found on the resident, indicating that the old patch was not removed before the new one was applied. This oversight was discovered when a nurse found two patches on the resident's shoulders, neither of which had dates or signatures. The resident's care plan required staff to monitor pain and medication administration, but the failure to remove the old patch before applying a new one suggests a lapse in following this plan. Interviews with staff confirmed the standard practice of removing the old patch before applying a new one, which was not adhered to in this instance. The incident was identified during a medication error investigation, highlighting a significant lapse in the administration process for pain management in the resident.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse, as evidenced by an incident involving two residents. Resident 12, who was admitted with dementia and depression, reported feeling uncomfortable and intimidated after Resident 20 yelled and cussed at them during a meal. Resident 20, who had a history of delusional disorders and mild cognitive impairment, exhibited verbal behaviors directed towards others. Despite staff being aware of the incident, it was not reported or documented as an abuse incident, and the behavior was dismissed as normal by some staff members. Multiple staff members, including CNAs and the Dietary Manager, were aware of the verbal altercation but did not take appropriate action to report it as abuse. Staff 21, a CNA, witnessed the incident and reassured Resident 12 that Resident 20's behavior was normal, failing to recognize it as verbal abuse. The facility's administrator acknowledged the deficiency, noting that the perception of Resident 20's behavior as normal needed correction. The lack of proper reporting and intervention placed residents at risk for abuse, as the facility did not adhere to its policy to prevent, identify, and investigate potential abuse instances.
Failure to Timely Assess and Treat Pressure Ulcer
Penalty
Summary
The facility failed to assess a newly identified pressure ulcer for a resident, which led to a delay in treatment and potential pain. The resident was admitted in March 2025 without any pressure ulcers. On March 18, 2025, during the evening shift, a CNA identified a new open area on the resident's left leg. However, the clinical record did not show that a nurse assessed this new open area on the same day. The following day, a CNA reported a new wound on the resident's heel that required assessment due to leakage. The wound was later assessed as a Stage II pressure ulcer with significant drainage. Staff interviews revealed communication lapses among the staff. The LPN assigned to the resident on March 18 was not informed by the CNA about the new pressure ulcer. Another LPN, who was informed by the CNA, instructed the CNA to notify the assigned LPN after her lunch break, but no follow-up occurred. The wound nurse was unsure of the exact time she was notified on March 19 but assessed and treated the wound once informed. The Director of Nursing Services and a Regional RN confirmed that the pressure ulcer was identified on March 18 but was not assessed or treated until the next day.
Inappropriate Dosing of Blood Pressure Medication
Penalty
Summary
The facility failed to provide appropriate dosing of medications for a resident with atrial fibrillation and high blood pressure. The resident was admitted in March 2025, and the care plan required medications to be administered according to physician orders. The March 2025 Medication Administration Record (MAR) specified that hydralazine should be administered three times daily and held if the systolic blood pressure was less than 120. However, the resident received hydralazine on multiple occasions with systolic blood pressures below 120, including readings of 119, 104, 108, and 115. Staff members, including an RN and an LPN, acknowledged administering the medication outside the prescribed parameters. The Director of Nursing Services confirmed that physician orders were not followed.
Failure to Provide Dental Services for Resident with Identified Dental Issues
Penalty
Summary
The facility failed to provide necessary dental services to a resident who was admitted with a diagnosis of stroke and identified dental issues, including likely cavities and broken molars. The resident's admission Minimum Data Set (MDS) indicated these dental issues, but the subsequent care conference did not address whether the resident or their representative wanted a dental assessment. Observations showed the resident eating without signs of pain, but staff interviews revealed a lack of follow-up on the dental issues. Staff 17 from Social Services admitted not reaching out to the resident's representative to offer dental services, and Staff 15, an LPN Resident Care Manager, acknowledged the dental issues but did not discuss them with the resident's representative. The Director of Nursing Services (DNS) and Regional RN confirmed that the MDS should have triggered a dental referral, which was not made.
Infection Control Deficiency in Laundry Room
Penalty
Summary
The facility failed to ensure that clean items were not stored in contaminated areas, specifically in the laundry room, which posed a risk of cross-contamination to residents. During an observation on March 26, 2025, it was noted that approximately 15 pillows, four uncovered styrofoam cushions, and a triangular wedge were stored on the dirty side of the laundry room. Staff 35, responsible for laundry and housekeeping, stated that these items had been stored there for about a month and had reported her concerns to the maintenance director, but the items were not removed. Staff 36, the Assistant Maintenance Director, confirmed placing the items in the laundry room on the soiled linen side and admitted to being unaware of the infection control issue. On March 28, 2025, the Administrator and Director of Nursing Services were informed of these findings and acknowledged the infection control concern due to potential cross-contamination.
Failure to Investigate Allegations of Abuse and Injuries
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and injuries of unknown origin for three residents. Resident 4, who was admitted with severe cognitive impairment, was observed with a bruise under the left eye. Despite multiple staff members being involved in the resident's care, witness statements were not collected from all CNAs involved. Staff members acknowledged the lack of follow-up and incomplete documentation regarding the incident. The facility's administration confirmed the investigation was neither thorough nor complete. In another incident, the facility failed to conduct a thorough investigation of an alleged inappropriate touching incident involving Residents 7 and 19. The incident report was incomplete, lacking critical details such as the time, location, and witness information. Staff members involved did not follow the facility's abuse protocol, and the administration acknowledged the failure to conduct a comprehensive investigation. These deficiencies placed residents at risk for abuse and demonstrated a lack of adherence to proper investigative procedures.
Failure to Follow Physician Orders and Medication Administration Protocols
Penalty
Summary
The facility failed to adhere to physician orders and provide necessary medications for four residents, leading to unmet care needs. Resident 6, who was admitted with a stroke diagnosis, did not receive bowel care medication as per the physician's order after five days without a bowel movement. Despite the protocol requiring administration of specific laxatives and notification of the provider, these steps were not followed, as acknowledged by the Director of Nursing Services. Resident 19, with a history of stroke and falls, experienced an unwitnessed fall on March 11, 2025. The facility's protocol required neuro checks and vital sign monitoring for 72 hours post-fall, but there was no documentation of these checks being completed. Staff members were aware of the protocol, but the Registered Nurse responsible for the fall investigation admitted to not ensuring the completion of the required checks. Resident 25, receiving hospice care for heart failure, was administered nitroglycerin for chest pain without notifying hospice as required by the physician's order. The hospice director confirmed they were not informed of the medication administration. Additionally, Resident 84, diagnosed with chronic pancreatitis, did not receive Zenpep medication due to the facility's failure to obtain it or find an alternative, despite the resident experiencing symptoms like nausea and diarrhea after the medication was discontinued.
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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