Lebanon Veterans Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Lebanon, Oregon.
- Location
- 600 North 5th Street, Lebanon, Oregon 97355
- CMS Provider Number
- 385280
- Inspections on file
- 20
- Latest survey
- September 9, 2025
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Lebanon Veterans Home during CMS and state inspections, most recent first.
The facility failed to inform a resident about changes in their standing frame therapy, leading to missed sessions, and did not obtain consent from another resident's responsible party before increasing the dosage of an antipsychotic medication.
A resident with dementia and urinary retention experienced red-tinged urine and severe abdominal pain, but the physician was not notified. The resident was later diagnosed with a UTI, hematuria, and sepsis, leading to hospitalization. Staff acknowledged the need to notify the physician, but no documentation was found.
The facility failed to provide timely Notice of Medicare Non-Coverage (NOMNC) for a resident admitted with heart attack and dehydration. The NOMNC was signed a day before the last covered day, and it was confirmed that the notice was not provided within the required timeframe.
A resident's grievance about activity rule changes and alleged prejudice was not addressed promptly due to an insufficient grievance policy and delayed response by the facility. The grievance policy lacked clear timeframes and did not acknowledge oral or anonymous grievances, leading to a 15-day delay in communication with the resident.
A facility failed to document and conduct a Significant Change MDS assessment for a resident whose condition had significantly deteriorated, including cognitive decline, increased pain, and worsening pressure ulcers. Despite these changes, no significant change assessment was considered or ruled out, placing the resident at risk for unassessed needs.
The facility failed to revise care plan interventions for three residents, leading to unmet needs. One resident's care plan did not reflect a significant decline in mobility, another's care plan lacked necessary fall prevention measures, and a third's care plan was not updated to reflect changes in preferences.
A resident with multiple sclerosis and spinal degeneration did not receive the required assistance with bathing due to staffing shortages. Despite filing a grievance, the resident continued to miss expected showers, and staff confirmed the difficulty in completing the task due to being short-handed.
The facility failed to monitor a resident for a change of condition, make a urology appointment, and follow physician orders for two residents. One resident exhibited UTI symptoms and was hospitalized with sepsis, while another resident did not receive prescribed Kefir due to unavailability, and staff failed to notify the physician.
The facility failed to accurately assess and document pressure ulcers for two residents, leading to a risk of worsening wounds. One resident's sacral wound progressed to a Stage 4 pressure ulcer without proper documentation or inclusion in the care plan, while another resident's wound assessments lacked comprehensive details and were often incomplete.
The facility failed to assess a resident's ability to transfer from a reclining chair and did not timely investigate falls for two residents. One resident with dementia was observed attempting to transfer from a recliner with elevated leg rests, increasing fall risk. Another resident experienced two falls, with investigations delayed by several days.
The facility failed to obtain orders for oxygen for a resident with COPD. The resident used oxygen as needed, but no orders were found in their medical record. Staff confirmed the resident's use of oxygen without proper orders.
A resident with a diagnosis of partial intestinal obstruction was administered both Loperamide and Senna simultaneously due to an incorrect entry in clinical records. This led to the resident not having a bowel movement for five days, requiring additional interventions. The error was identified when staff noted the medications should not have been given together.
The facility failed to ensure complete and accurate records for a resident with diabetes. Despite physician orders to administer insulin three times a day, records showed missed doses on multiple occasions. Staff later claimed these records were marked in error and that the medication was administered as ordered.
The facility failed to practice proper infection control procedures for a resident with a Stage 4 pressure ulcer and did not sanitize resident care equipment between uses. An LPN did not perform hand hygiene after removing gloves during wound care, and a CNA did not sanitize equipment between residents.
The facility failed to protect two residents from abuse. One resident with dementia and PTSD was sexually abused by another resident with Alzheimer's Disease during a video call. In a separate incident, a resident with moderate cognitive impairment was struck by an object thrown by another resident with dementia and PTSD. Both incidents were witnessed by staff, but only the sexual abuse was substantiated.
The facility failed to timely investigate an abuse allegation involving a resident with panic disorder, dementia, and PTSD, and another resident with Alzheimer's Disease. The incident occurred during a video call when one resident rubbed the other's chest area. The investigation, which confirmed sexual abuse, was not completed in a timely manner.
Failure to Inform Residents and Obtain Consent for Medication and Therapy Changes
Penalty
Summary
The facility failed to provide adequate information and communication regarding the use of an antipsychotic medication and changes in therapy services for two residents. Resident 80, diagnosed with multiple sclerosis and spinal degeneration, was initially scheduled to use a standing frame three times a week. However, the therapy was changed to a PRN basis without informing the resident. As a result, the resident was unaware that they needed to request the standing frame service, leading to a lack of therapy sessions. Staff confirmed that the resident was not notified of the changes, and the resident expressed confusion and frustration over the lack of communication. Resident 118, diagnosed with bipolar disorder and dementia, was prescribed Seroquel, an antipsychotic medication. The dosage was increased without obtaining consent from the resident's responsible party. There was no documentation in the clinical records indicating that the risks and benefits of the medication were communicated to the responsible party. Staff confirmed that consent was not received for the use of Seroquel, indicating a failure to provide necessary information and obtain proper authorization before administering the medication.
Failure to Notify Physician of Change in Condition
Penalty
Summary
The facility failed to notify a resident's physician of a change in condition for a resident diagnosed with dementia, urinary retention, and an irregular heartbeat. The resident was observed to have red-tinged urine on two separate occasions, but the physician was not notified. On the first occasion, the resident denied pain, and there was no indication that the physician was informed. On the second occasion, the resident reported a stomach ache and was found to have blood on their incontinent brief and genitalia, yet again, the physician was not notified. The resident's urinary status was not assessed for several days following these observations. The situation escalated when the resident experienced severe abdominal pain, shaking, and crying, leading to their transport to the hospital. The resident was diagnosed with urinary retention, a UTI with hematuria, and sepsis with sudden onset of kidney failure. Interviews with staff revealed that there were difficulties in obtaining orders from the physician for urinalysis, and it was acknowledged that the physician should have been notified of the symptoms. The Director of Nursing Services confirmed that there was no documentation indicating the physician was notified of the resident's condition changes.
Failure to Provide Timely Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide timely Notice of Medicare Non-Coverage (NOMNC) for a resident reviewed for notices. The resident was admitted in 2024 with diagnoses including heart attack and dehydration. The NOMNC documented the last covered day as 4/3/24 and was signed by the resident on 4/2/24. On 5/2/24, a Social Services Designee confirmed that the notice was not provided within the required timeframe to the resident.
Insufficient Grievance Policy and Delayed Response
Penalty
Summary
The facility failed to develop a sufficient grievance policy and provide a timely response to a grievance filed by a resident. The facility's grievance policy, revised in December 2023, did not specify a reasonable expected timeframe for reviewing grievances and neglected to include that residents had the right to file grievances orally or anonymously and obtain a written decision. A resident expressed dissatisfaction with rule changes to a game activity and alleged prejudice from activity staff in a hand-written letter to the Recreation Director. Despite the letter being observed by the Social Service Designee on the same day it was written, the Grievance Officer did not read it until 16 days later, resulting in a delayed response to the resident's concerns. The resident stated that they had not received any communication about their concerns for 15 days after filing the complaint. The Assistant Administrator confirmed the delay, attributing it to a team effort to determine the best way to handle the information in the letter. The Social Service Designee did not consider the letter a grievance because it was not on the official grievance form. A late conversation with the resident regarding their concerns was conducted 19 days after the letter was written, highlighting the insufficiency of the facility's grievance policy when it was updated in December 2023.
Failure to Conduct Significant Change MDS Assessment
Penalty
Summary
The facility failed to document and conduct a Significant Change MDS assessment within the required timeframe for a resident reviewed for nutrition. The resident was admitted to the facility in 2023 with diagnoses including diabetes, pressure ulcer, and dementia. Initially, the resident was cognitively intact with no mood or behavioral concerns. However, by the next quarterly MDS assessment, the resident's cognitive status had declined to moderate impairment, and they exhibited depressive symptoms, behavioral issues, and increased pain levels. Additionally, the resident's pressure ulcer had worsened from Stage 3 to Stage 4, and they were administered a broader range of medications, including antipsychotics, antianxiety, anticoagulants, and opioids. Despite these significant changes in the resident's condition, there was no documentation in the clinical records to indicate that a significant change assessment was considered or ruled out. When questioned, a staff member stated they did not know why the assessment was not completed. This oversight placed the resident at risk for unassessed needs and potentially inadequate care adjustments.
Failure to Revise Care Plan Interventions
Penalty
Summary
The facility failed to revise care plan interventions for three residents, leading to unmet needs. Resident 38, diagnosed with Parkinson's disease, had a care plan indicating the need for walks despite a significant decline in mobility. The resident could no longer walk and required maximum assistance for balance, but the care plan was not updated to reflect these changes. Staff confirmed the resident's decline and the outdated care plan. Resident 121, with a history of falls and moderate cognitive impairment, had a care plan that did not include the use of room and bed sensors despite their effectiveness in preventing falls. The resident experienced a fall, and the care plan lacked documentation of these necessary interventions. Staff confirmed the omission of the room and bed sensors in the care plan. Resident 101, diagnosed with dementia, had a care plan indicating enjoyment of bird watching, but after moving to a new room, the resident no longer liked to watch birds and preferred the window blinds to be shut. Staff confirmed the resident's change in preference, but the care plan was not updated to reflect this. The recreational director acknowledged that the care plan might not have been updated to reflect the resident's current preferences. These failures in updating care plans placed the residents at risk for unmet needs and inadequate care.
Failure to Provide Required Assistance with ADLs
Penalty
Summary
The facility failed to ensure that a dependent resident received the required assistance with activities of daily living (ADLs), specifically bathing. Resident 80, who has multiple sclerosis and spinal degeneration, was admitted in 2020 and required one staff member to assist with bathing. Despite this, the resident's shower calendar for March and April 2024 indicated that the resident received only one shower per week on specific dates, with no showers provided on Sundays as expected. The resident confirmed that they had not received the expected Sunday showers and had filed a grievance, but the issue persisted due to staffing shortages. Staff members corroborated the resident's claims, noting that it was difficult to complete the resident's shower task at night due to being short-handed. Staff 12 and Staff 27 both indicated that the resident's shower required significant staff assistance, which was challenging to provide due to staffing issues. The Assistant Administrator confirmed that the resident had raised concerns about missed showers in January 2024 and expected follow-up showers to be provided if weekend showers were missed. The Director of Nursing Services (DNS) and Assistant DNS acknowledged that the staffing coordinator had been directed to ensure that the same resident unit was not always short-handed, but teamwork was necessary to meet the resident's needs, which did not occur.
Failure to Monitor Condition and Follow Physician Orders
Penalty
Summary
The facility failed to monitor a resident for a change of condition, make a urology appointment, and follow physician orders for two residents reviewed for UTIs and medications. Resident 36, who was admitted with a diagnosis of dementia, exhibited symptoms of a UTI, including red-tinged urine and abdominal pain, but staff did not consistently monitor these symptoms or notify the physician. The resident was eventually hospitalized with urinary retention, UTI with hematuria, and sepsis. Additionally, there was no documentation that a referral to urology was completed as ordered upon discharge from the hospital. Resident 118, admitted with diagnoses including a pressure ulcer and diabetes, was prescribed Kefir to be administered twice daily. However, the medication administration record indicated that Kefir was not available on multiple occasions, and staff failed to notify the physician about its unavailability. This lack of communication and failure to follow physician orders placed the resident at risk for unmet medical needs.
Inadequate Pressure Ulcer Assessment and Documentation
Penalty
Summary
The facility failed to accurately assess and document pressure ulcers for two residents, leading to a risk of worsening wounds. Resident 59, who was admitted with paraplegia, had a sacral wound initially identified as moisture-associated damage. Over time, the wound was inconsistently documented and eventually identified as a Stage 4 pressure ulcer. Despite the wound's progression, it was not correctly assessed or included in the care plan, and the resident required hospitalization for wound debridement. Staff acknowledged the misclassification and lack of proper documentation for the wound's severity and progression. Resident 118, admitted with a sacral pressure ulcer, also experienced inadequate wound assessments. The evaluations from January to April lacked comprehensive details such as wound bed description, drainage, surrounding tissue condition, pain level, and treatment. On several occasions, the evaluations were incomplete or not performed at all. The Director of Nursing Services confirmed that the evaluations should have been fully comprehensive, indicating a failure in the facility's wound care documentation and assessment processes.
Failure to Assess Transfer Ability and Timely Investigate Falls
Penalty
Summary
The facility failed to assess and care plan a resident's ability to transfer from a reclining chair and timely investigate a fall for two residents. Resident 142, who was admitted with a diagnosis of dementia, was observed in a recliner with elevated leg rests and was not assessed for her/his ability to use the remote control to lower the leg rests. Staff acknowledged that many residents in the memory care unit, including Resident 142, were not able to use the remote control. On multiple occasions, Resident 142 was observed attempting to transfer out of the recliner with elevated leg rests, increasing the risk of falls. The care plan did not direct staff to ensure leg rests were down if staff were not in the common area and the resident was asleep. Staff confirmed that there were times when all staff were assisting other residents and may not be available to help Resident 142, who was unsteady when standing without assistance. Resident 121, admitted with diagnoses including anxiety and cramp and spasm disorder, experienced two falls that were not investigated in a timely manner. A post-fall assessment revealed that Resident 121 was found on the floor, but the investigation was completed seven days later. Another post-fall assessment indicated that Resident 121 reported a fall in the bathroom, but the investigation was completed eight days later. Staff confirmed that the fall investigations were not completed in a timely manner, which could have delayed identifying and addressing the causes of the falls.
Failure to Obtain Oxygen Orders for Resident with COPD
Penalty
Summary
The facility failed to obtain orders for oxygen for a resident with chronic obstructive pulmonary disease (COPD). The resident, admitted in December 2022, had a care plan dated March 3, 2023, for as-needed oxygen. On April 8, 2024, a progress note indicated the resident received oxygen due to respiratory difficulties and shortness of breath. An oxygen concentrator was observed by the resident's bed on April 29, 2024, and the resident stated they used oxygen a couple of times a week, usually in the evenings. A review of the resident's medical record on May 1, 2024, revealed no evidence of oxygen orders. Staff interviews on May 2, 2024, confirmed the resident used oxygen as needed but had no orders for it.
Significant Medication Error Involving Loperamide and Senna
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, specifically for one resident who was administered both Loperamide and Senna simultaneously. The resident, who was admitted with a diagnosis of partial intestinal obstruction, had physician orders for Loperamide to treat diarrhea and Senna to treat constipation. These medications were administered daily from February through April, despite the conflicting purposes of the medications. This error was due to an incorrect entry in the clinical records, which led to the resident receiving both medications concurrently instead of Loperamide being administered on a PRN basis. As a result of this medication error, the resident did not have a bowel movement for five days in April, prompting the administration of a suppository and Miralax for bowel care. The error was identified when a staff member noted that the resident should not have been given both medications at the same time. The incorrect order in the clinical records was acknowledged as a significant medication error, placing the resident's health status at risk.
Incomplete and Inaccurate Resident Records for Medication Administration
Penalty
Summary
The facility failed to ensure resident records were complete and accurate for one resident reviewed for medications. Resident 118, who was admitted in 2023 with a diagnosis of diabetes, had a physician order dated 3/11/24 to administer insulin injections three times a day starting from 10/22/23. However, the Diabetic Orders report for April 2024 documented that the resident was not administered insulin on multiple occasions because the resident was sleeping. Specifically, the missed administrations were recorded on 4/1/24 at 5:00 PM, 4/13/24 at 7:00 AM, 4/14/24 at 7:00 AM, 4/16/24 at 12:00 PM, 4/21/24 at 12:00 PM, and 4/23/24 at 12:00 PM. On 5/3/24, Staff 21 (RCM) stated that these dates were marked in error and that the resident was actually administered the medication as ordered by the physician.
Infection Control Deficiencies
Penalty
Summary
The facility failed to practice proper infection control procedures for a resident with a Stage 4 pressure ulcer and did not sanitize resident care equipment between uses. Resident 59, admitted in March 2017 with paraplegia, had a Stage 4 pressure ulcer on the sacrum as of April 29, 2024. On May 1, 2024, an LPN was observed performing wound care for Resident 59 without performing hand hygiene after removing gloves and before applying new ones. The LPN and a CNA both stated they were unaware of the need to perform hand hygiene in this situation. Additionally, on April 29, 2024, a CNA was observed completing blood pressure and oxygenation checks for multiple residents without sanitizing the equipment between uses. The CNA acknowledged not sanitizing the equipment after each resident.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure residents were free from sexual and physical abuse, affecting two residents. Resident 38, who has diagnoses including panic disorder, dementia, and PTSD, was sexually abused by Resident 141, who has Alzheimer's Disease. During a video call with a family member, Resident 141 reached over and rubbed Resident 38's chest area. This incident was witnessed by the family member and a CNA, and the facility substantiated the sexual abuse. The incident was reported, and staff intervened by moving Resident 38 to a different location and escorting Resident 141 back to their unit. In another incident, Resident 108, who has a history of trauma and moderate cognitive impairment, was physically abused by Resident 139, who has dementia, psychotic disturbance, mood disturbance, anxiety, and PTSD. Resident 139's behaviors escalated, leading them to throw a handheld game into Resident 108's room, striking Resident 108 on the side of the face. This incident was witnessed by two CNAs, and although no injuries were identified, the facility did not substantiate the abuse, attributing Resident 139's actions to a PTSD trigger and agitation. Staff continued to monitor Resident 108 for any abnormalities following the incident.
Failure to Timely Investigate Abuse Allegation
Penalty
Summary
The facility failed to timely investigate an abuse allegation involving Resident 38, who has diagnoses including panic disorder, dementia, and PTSD, and Resident 141, who has Alzheimer's Disease. On 4/4/24, while Resident 38 was on a video call with a family member, Resident 141 reached over and rubbed Resident 38's chest area. The family member intervened by telling Resident 141 to keep their hands to themselves. The facility's investigation, which took place from 4/4/24 to 4/10/24, substantiated the sexual abuse. However, Staff 21 confirmed on 5/3/24 that the investigation was not completed in a timely manner.
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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