Laurelhurst Post Acute & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Portland, Oregon.
- Location
- 3060 Se Stark Street, Portland, Oregon 97214
- CMS Provider Number
- 385010
- Inspections on file
- 21
- Latest survey
- November 4, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Laurelhurst Post Acute & Rehabilitation during CMS and state inspections, most recent first.
Several residents with conditions such as dysphagia, malnutrition, and failure to thrive did not receive their prescribed Medpass 2.0 nutritional supplements on multiple days. This occurred because the Dietary Manager faced delays in administrative approval for orders and was restricted in the amount that could be purchased, resulting in insufficient supply. Nursing staff and the DNS confirmed the supplement was frequently unavailable, and residents did not receive it as ordered.
A resident who required two-person assistance for transfers and was incontinent was not assisted to bed or provided incontinence care at her preferred time due to a staffing shortage, resulting in prolonged discomfort and soiled clothing. Staff confirmed that only one CNA was available for several hours, leading to a significant delay in meeting the resident's needs.
A resident with a recent fracture was discharged home without a completed home health referral or necessary caregiver, PT, and OT support services, despite prior care planning and physician recommendations. The resident and family had to arrange for care independently after discharge, and facility leadership acknowledged the lapse.
The facility failed to dispose of expired medications in several storage areas, including medication rooms and carts. Expired items such as nicotine patches, saline spray, and vitamin tablets were found, and staff admitted to not knowing the medication storage policy. The policy requires expired medications to be destroyed, but it did not specifically address vials, contributing to the oversight.
The facility failed to properly label and store food items in the kitchen and dining room refrigerator units and freezers, risking foodborne illness for residents. Unlabeled and undated food items, including filets, patties, and croutons, were found in the main kitchen. Expired and unlabeled items were also found in the second floor ICF unit freezer and on the third and fourth floors. Staff acknowledged these issues and stated that dietary staff were responsible for monitoring and discarding expired products.
A resident was discharged with instructions to take home all their medications, including 112 Oxycodone tablets. However, 56 tablets were missing upon arrival home. Despite the resident's report, the issue was not escalated, and facility records showed discrepancies, with some tablets being destroyed by staff. Key staff were unaware of the issue until months later.
A resident was discharged with missing Oxycodone tablets, which were not reported to management or the State Agency by the LPN or CMA who were informed. The DNS was unaware of the incident until months later, highlighting a failure in the facility's reporting procedures.
Two residents were not assessed for safe self-administration of medications, leading to potential risks. One resident, with kidney failure, had topical medications at bedside without assessment, while another, with dementia and diabetes, used cough drops frequently without safety evaluation. Staff removed the items upon discovery, confirming the lack of prior assessment.
A resident with hemiparesis, hemiplegia, and aphasia was not provided with necessary transfer assistance, despite being dependent on staff for transfers. The resident remained in bed over several days, although their care plan required the use of a mechanical lift and a tilt-in-space wheelchair. Staff interviews revealed confusion about who was responsible for transfers, with some believing only therapy staff could perform them, while the Director of Rehabilitation confirmed no such restriction existed.
Two residents in an LTC facility were not provided with activities tailored to their interests, leading to isolation and lack of engagement. One resident, with colon cancer and adjustment disorder, preferred music and reading but was not offered these activities. Another resident, with hemiparesis and aphasia, enjoyed being outside and listening to music but was not given these opportunities. Staff were unaware of the residents' preferences, and the facility's activity calendar did not align with their interests.
A resident with depression and dementia experienced undignified treatment from a CNA, who made inappropriate comments about the resident's incontinence and accused the resident of trying to get her fired. The facility's policy on dignity was violated, and the CNA was terminated following the incident. The resident reported feeling safe after the CNA's removal.
Failure to Provide Ordered Nutritional Supplements Due to Administrative Delays and Supply Restrictions
Penalty
Summary
The facility failed to provide nutritional supplements as ordered for four out of five residents reviewed for nutritional supplements. Multiple residents with diagnoses such as dysphagia, malnutrition, Parkinson's disease, stroke, dementia, and failure to thrive had physician orders for Medpass 2.0, a nutritional supplement, to be administered multiple times daily. Medication Administration Records (MARs) for these residents showed repeated entries indicating the supplement was unavailable on several days during the review period. Staff interviews revealed that the Dietary Manager was responsible for ordering Medpass 2.0 but faced delays in administrative approval for purchase orders, as well as restrictions on the quantity that could be ordered due to budget limitations set by administration. These delays and restrictions resulted in insufficient supply and the supplement being unavailable for residents on multiple days. Nursing staff confirmed the supplement was often unavailable, and attempts to locate additional supply within the facility were unsuccessful. Residents and staff confirmed that the prescribed nutritional supplements were not received as ordered on the documented dates. The Director of Nursing Services (DNS) verified that the '9' notation on the MAR indicated the supplement was not available and confirmed the missed doses for each affected resident. The lack of timely administrative approval and supply limitations directly led to the failure to provide the ordered nutritional supplements.
Failure to Provide Timely ADL and Transfer Assistance Due to Staffing Shortage
Penalty
Summary
A deficiency occurred when a resident with diagnoses including breast cancer and congestive heart failure, who was cognitively intact and required two-person assistance for bed mobility and transfers, was not provided timely care according to her preferences and care plan. The resident preferred to go to bed between 4:30 PM and 5:00 PM, but on the evening in question, was not assisted to bed until approximately 9:00 PM. During this period, the resident remained in her wheelchair, resulting in pain in her legs and being soaked in urine by the time she was finally transferred to bed and changed. The delay was attributed to a staffing shortage, with only one CNA working on the floor for approximately four hours, responsible for 20 residents, several of whom required two-person assistance. Multiple staff interviews confirmed the staffing shortage and the resulting delay in care. The resident's grievance and statements from staff, including the RN, CNA, Resident Care Manager/LPN, and DNS, all acknowledged that the resident's needs and preferences were not met due to inadequate staffing. The incident was verified by the former administrator, who confirmed that the delay in care was a result of the staffing failure on that evening.
Failure to Ensure Safe Discharge with Home Health Services
Penalty
Summary
A resident with a fibular fracture was admitted to the facility and had a discharge care plan indicating an anticipated return home, with arrangements to be made for home health (HH), caregiver support, physical therapy (PT), and occupational therapy (OT). Physician and social services notes confirmed the need for these services, and a referral to a home health agency was initially sent. However, when the home health agency attempted to complete the referral, facility staff informed them to cancel it, as the resident was reportedly no longer planning to discharge at that time. Despite this, the resident was ultimately discharged home without a completed home health referral or the necessary support services in place. The resident reported being without caregiver supports until arranging services independently through their physician, and a family member had to quit two jobs to provide care until home health services were established. Facility leadership acknowledged that the resident was discharged without the required home health, PT, and OT services.
Failure to Dispose of Expired Medications
Penalty
Summary
The facility failed to properly dispose of expired medications across multiple medication storage areas, including three medication storage rooms, four medication carts, and one medication storage refrigerator. This oversight was identified during observations and interviews with staff members who acknowledged the presence of expired medications. The expired medications included nicotine transdermal patches, saline nasal spray, liquid cough suppressant, liquid acid reducer, vitamin C tablets, Vitamin A&D ointment, triple antibiotic ointment, and sodium chloride tablets. Additionally, multi-dose vials of Tuberculin were found without open dates, contrary to manufacturer instructions that require them to be dated and discarded after 30 days. Staff members admitted to not knowing the facility's medication storage policy, which contributed to the failure to discard expired medications. The facility's policy, last revised in November 2020, did not specifically address the handling of vials of medications, although it did state that outdated medications should be destroyed. Staff 3 confirmed that the expectation was for all staff handling medications to be familiar with and adhere to the medication storage policy, which includes destroying expired medications and ordering replacements if necessary.
Improper Food Labeling and Storage in Facility
Penalty
Summary
The facility failed to ensure proper labeling and storage of food items in the kitchen and dining room refrigerator units and freezers, which could lead to foodborne illness and unappetizing meals for residents. During observations, surveyors found unlabeled and undated food items, including a plastic-wrapped stainless steel container with white filets, frozen red patties, and an open bag of croutons in the main kitchen. Staff 4, the Dietary Manager, acknowledged these issues and stated that food items were expected to be labeled and dated with the date they were prepared or opened. Additionally, dented cans of apple pie filling, black beans, and diced peaches were found in the dry storage room, which Staff 4 admitted should have been removed from the pantry. On the second floor Intermediate Care Facility (ICF) unit, an unopened package of expired frozen purple Ube steamed buns was found in the freezer, unlabeled and undated. Staff 25, a CNA, was unable to confirm ownership of the package and acknowledged the expiration date. Staff 18, an LPN Resident Care Manager, confirmed the expired package and stated that dietary staff were responsible for cleaning out and monitoring refrigerator contents. Staff 20, another CNA, explained that it was the staff's responsibility to label and date resident food items before placing them in the unit refrigerator. Similar issues were observed on the third and fourth floors of the ICF building, where several unlabeled and undated food items were found in the refrigerators and freezers. These included a vanilla nutritional supplement, a tumbler with white liquid, a plastic container with red chunks, sour cream, frozen blueberries, and homemade popsicles. Staff 19, a CNA, acknowledged the unlabeled and undated items, while Staff 18 and Staff 20 reiterated the responsibility of dietary staff and CNAs in maintaining proper labeling and dating of food items. Staff 4, the Dietary Manager, confirmed that dietary staff were expected to restock and check refrigerators daily, discarding expired products to prevent health hazards for residents.
Misappropriation of Resident's Oxycodone Tablets
Penalty
Summary
The facility failed to ensure that a resident was free from misappropriation of their medications, specifically Oxycodone tablets. The resident, who was cognitively intact and admitted with a hip fracture and lung disease, was discharged with instructions to take home all their medications, including 112 Oxycodone tablets. However, upon discharge, the resident reported that 56 Oxycodone tablets were missing from the bag of medications they received. Despite the resident's report to a staff member, the issue was not escalated to upper management, and the missing tablets were not accounted for. The facility's records showed discrepancies, with a narcotic logbook indicating the resident signed for all 112 tablets, yet a destruction log showed that 56 tablets were destroyed by facility staff. Staff members involved in the discharge process and subsequent communication with the resident failed to report the missing medication to upper management. The Director of Nursing Services and other staff were unaware of the issue until months later, acknowledging that the tablets should have been sent home with the resident and expressing uncertainty about why the tablets were destroyed.
Failure to Report Misappropriation of Medications
Penalty
Summary
The facility failed to report an incident of alleged misappropriation of medications to the State Agency in a timely manner, as required by their policy. A resident, who was cognitively intact, was discharged from the facility with a stapled paper bag containing their belongings and medications. Upon arriving home, the resident discovered that the Oxycodone tablets they had signed for were missing. The resident reported the missing medication to a Licensed Practical Nurse (LPN) at the facility, who confirmed that the Oxycodone was placed in the bag but failed to escalate the issue to upper management or the State Agency. Additionally, a Certified Medication Aide (CMA) was aware of the resident's report of the missing Oxycodone but also did not report the incident to upper management or the State Agency. The Director of Nursing Services (DNS) stated that it was her expectation for staff to report such allegations to her or a Resident Care Manager. However, the DNS was only made aware of the incident several months later, indicating a breakdown in the facility's reporting procedures. This failure to report placed residents at risk for diversion of medications and misappropriation of property.
Failure to Assess Residents for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to assess two residents for the safe self-administration of medications, which placed them at risk for an unsafe medication regimen. Resident 65, admitted with kidney failure, was observed with tubes of Zinc Oxide External Paste and Hydrocortisone External Cream at her/his bedside, which she/he used as needed. Despite having a BIMS score indicating cognitive intactness, there was no evidence in the health record that Resident 65 was assessed for self-administration of these medications. Staff confirmed the lack of assessment and removed the medications from the resident's room. Similarly, Resident 69, admitted with dementia and diabetes, was found with cough drops at her/his bedside, which she/he used frequently. Although Resident 69 also had a BIMS score indicating cognitive intactness, there was no documentation of an assessment for the safe self-administration of cough drops. Staff were unaware of the resident's use of cough drops and removed them upon discovery, confirming that no assessment had been completed to ensure safety.
Failure to Provide Transfer Assistance for Resident
Penalty
Summary
The facility failed to ensure that a resident, who was unable to perform activities of daily living (ADLs) independently, received the necessary transfer assistance. The resident, admitted with conditions including hemiparesis, hemiplegia, and aphasia following a stroke, was dependent on staff for transfers as indicated in their admission MDS. Despite having a care plan that required the use of a mechanical lift for all transfers and a tilt-in-space wheelchair provided by therapy, the resident was observed to remain in bed over several days without being transferred to their wheelchair. Interviews with staff revealed confusion and miscommunication regarding the resident's transfer assistance. Family members and staff expressed a desire for the resident to be transferred to their wheelchair, as the resident enjoyed being around people and out of their room. However, some staff believed that only therapy staff were allowed to perform the transfers, while others were unsure of the reasons behind this restriction. The Director of Rehabilitation confirmed that there was no directive from the therapy department to keep the resident in bed, and the Director of Nursing Services acknowledged the lack of transfer assistance, expecting nursing staff to provide such assistance and to reapproach the resident if they initially refused.
Failure to Provide Individualized Activity Programs
Penalty
Summary
The facility failed to provide an ongoing program to support individual activity interests and preferences for two residents, placing them at risk for isolation and lack of social interaction. Resident 72, admitted with diagnoses including colon cancer and adjustment disorder with anxiety and depression, had specific activity preferences such as listening to classical music, reading non-fiction books, and going outside. However, from February to March, the resident did not participate in any group or self-directed activities and received minimal one-to-one visits. Observations revealed the resident was often in bed with the television on, and staff were unaware of the resident's interests, failing to offer activities like book reviews or outdoor time. Resident 90, admitted with hemiparesis, hemiplegia, and aphasia following a stroke, also experienced a lack of tailored activities. The resident's care plan indicated a preference for in-room activities, classical music, and going outside. However, the resident participated in only one group activity and received limited one-to-one visits. Observations showed the resident spent most of the time in bed watching television, with no evidence of being offered opportunities to go outside or engage in preferred activities. Staff interviews revealed a lack of awareness and action regarding the resident's interests and needs. The facility's activity calendar showed scheduled activities, but these did not align with the specific interests of Residents 72 and 90. Staff, including the Activities Director, acknowledged the failure to offer activities tailored to the residents' preferences. The lack of individualized activity programming and staff engagement contributed to the deficiency, as residents were not encouraged or assisted to participate in activities that matched their interests and capabilities.
Failure to Provide Dignified Care to Resident
Penalty
Summary
The facility failed to provide dignified and respectful care to a resident diagnosed with depression and dementia. The resident reported an incident involving a CNA, identified as Staff 3, who allegedly yelled at the resident and made undignified comments about the resident's incontinence. The resident expressed fear and confusion regarding the CNA's behavior, which included accusations of the resident trying to get the CNA fired and comments about the resident's incontinence. These actions were contrary to the facility's policy on dignity, which emphasizes treating residents with respect and enhancing their sense of well-being. The incident was documented in an Alleged Abuse report, and it was noted that the resident felt safe after the CNA was terminated. Interviews with staff revealed that the CNA had a history of making undignified statements to residents, and the incident with this resident was considered the final concern regarding respect and dignity. The facility's administrator confirmed that the CNA's statements were undignified, and the previous Director of Nursing Services acknowledged the resident's sensitivity and the inappropriate nature of the CNA's comments.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
