Life Care Center Of Coos Bay
Inspection history, citations, penalties and survey trends for this long-term care facility in Coos Bay, Oregon.
- Location
- 2890 Ocean Blvd, Coos Bay, Oregon 97420
- CMS Provider Number
- 385157
- Inspections on file
- 17
- Latest survey
- December 19, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Life Care Center Of Coos Bay during CMS and state inspections, most recent first.
The facility failed to prevent accidents and update care plans for three residents, leading to falls and injuries. A resident with paralysis fell from a mechanical lift due to improper use by CNAs, while another with Parkinson's disease experienced multiple falls due to inadequate supervision and incomplete care plan updates. A third resident with a history of falls also had care plan deficiencies, contributing to repeated falls.
The facility failed to provide adequate pain management for two residents, resulting in unresolved severe pain. One resident with a pressure ulcer did not receive prescribed oxycodone for five days due to medication ordering issues, while another post-surgery resident was not given pain medication on admission despite authorization to use emergency supply, leading to an ER visit. Documentation was also lacking.
The facility did not ensure staffing information was posted in an accessible location and failed to provide accurate and complete data for several days. The Direct Care Staff Daily Report was placed above eye level behind the nurse's station, making it difficult to access. Additionally, the report was incomplete or missing data on multiple occasions, as acknowledged by the Staffing Coordinator.
The facility failed to implement enhanced barrier precautions (EBP) and transmission-based precautions for two residents with wounds, risking cross-contamination. A resident with rib fractures was not listed for EBP despite having a wound, and a physical therapist did not follow droplet precautions for another resident with a leg fracture, as they were not informed of the requirements.
The facility did not ensure CNAs received the required 12 hours of annual in-service training, as shown by records for five staff members. One CNA had no documented training, while others had less than the required hours. The DNS confirmed the deficiency, despite competency evaluations and training being conducted.
A facility failed to include a resident's guardian in care planning, as the guardian was not invited to care conferences since October 2023. The resident, diagnosed with autism, had a guardian who confirmed not being involved in care planning for a significant period. Despite staff efforts, no documentation was found to show the guardian's participation in care conferences.
The facility failed to document and follow up on advance directives for three residents, including one with rib fractures and another with diabetes and left-sided weakness. Despite care plans indicating the presence of advance directives, the clinical records lacked copies, and there was no documentation of offering or refusing directives. The Social Services Director acknowledged these deficiencies.
A resident with dementia was hospitalized following a change in condition, but the facility failed to notify the resident's representative, despite them being the first emergency contact. This deficiency was confirmed through interviews and a lack of documentation from the LPN responsible.
A facility failed to notify a resident's responsible party about a change in Medicare coverage. The resident, with moderate cognitive impairment, signed a Notice of Medicare Non-Coverage (NOMNC) form without the responsible party being informed. Staff interviews revealed a lapse in protocol, as the responsible party was not contacted or present during the signing, despite being known to the facility.
The facility failed to provide a safe and homelike environment for two residents due to uneven floors, causing furniture to roll and creating a risk of imbalance. One resident, with vertigo and unsteadiness, reported their room sloped visibly, while another resident required blocks under their bed to level it. Staff confirmed the issue, noting the building's U shape, and planned to move affected residents.
A resident with moderate cognitive impairment was involved in an incident with an agency LPN, who reportedly reacted aggressively after the resident pushed a bedside table into him. The LPN allegedly grabbed the resident's bed covers and pushed down on the resident's chest. Despite reports from witnesses and the resident's family, the facility did not investigate the incident, and documentation was missing.
A resident with moderate cognitive impairment was involved in an alleged abuse incident with an agency LPN, who reportedly had a physical altercation with the resident. Despite the incident being reported to the family, the facility failed to report it to the State Survey Agency, as required. Interviews confirmed the incident, and the facility's administration acknowledged the expectation to report such allegations.
A resident with cognitive impairment was allegedly abused by an agency LPN, who reportedly pushed down on the resident's chest after a confrontation. Despite the resident's fear and family notification, the facility failed to document an investigation into the incident, as confirmed by staff interviews.
The facility failed to update care plans for three residents, leading to unmet care needs. A resident with a shin wound had no care plan revision to address it. Another resident with a hand contracture required assistance with a soft hand roll, which was not included in the care plan. A third resident with a left ankle wound had no goals or interventions in their care plan. Staff acknowledged these oversights.
A resident with cognitive impairment and a stroke diagnosis was observed with long facial hair, despite preferring to be clean-shaven. The resident required assistance for ADLs, and a CNA acknowledged the resident had not been shaved for several days, contrary to the facility's routine of shaving on shower days.
The facility failed to provide care for a non-pressure skin injury and did not prepare a resident for a medical procedure. A resident with heart disease had a shin wound that was not assessed or treated properly, and the care plan was not updated. Another resident, admitted with a stroke, was not prepped for a sigmoidoscopy, leading to a delay in diagnosis. The lack of preparation was acknowledged by the DNS.
A resident with Parkinson's disease had contractures in their hands, but the facility failed to provide a treatment plan. The resident was able to communicate needs, and a family member was unaware of any ROM exercises being provided. The DNS confirmed the lack of a treatment plan.
A resident with an indwelling catheter experienced prolonged pain due to inadequate catheter care and documentation. Despite a care plan requiring regular catheter care and monitoring, staff failed to document urine output and address the resident's complaints of bladder pain. The issue was resolved only after a catheter change during the night shift, highlighting deficiencies in the facility's catheter care protocol.
A resident with Parkinson's disease and mental health disorders, who was at nutritional risk, did not receive scheduled snacks as per their care plan. The facility failed to document the provision of snacks, and the task was not correctly entered into the system, leading to a lack of adherence to the resident's nutritional care plan.
A facility failed to provide non-pharmacological interventions before administering medications and did not document a rationale for not reducing a resident's venlafaxine dose. The resident, diagnosed with dementia, was on multiple antidepressants, and a pharmacy consultation recommended tapering citalopram and reducing venlafaxine, but the latter was declined without rationale. Additionally, Ativan PRN was administered for anxiety without documented behaviors or non-pharmacological interventions.
The facility failed to obtain a blood sample for a resident with a stroke diagnosis, as instructed in the July 2024 TAR. Despite a request for the laboratory results, no additional information was provided, placing residents at risk for delayed treatment.
A resident with missing and decaying teeth was not offered a dental appointment, despite being cognitively intact and reporting cavities. The facility's staff failed to follow up on identified dental concerns, leading to a deficiency in care.
A resident with a UTI was inappropriately administered Cephalexin without confirming its effectiveness, leading to unnecessary antibiotic use. Despite urine culture results showing resistance to Cephalexin, it was not discontinued when Meropenem was started, resulting in both antibiotics being administered simultaneously. The DNS acknowledged the error.
Failure to Prevent Accidents and Update Care Plans
Penalty
Summary
The facility failed to ensure the safety of residents and update care plans following accidents, as evidenced by incidents involving three residents. Resident 21, who has left side paralysis and moderate cognitive impairment, fell from a mechanical lift due to the failure of CNAs to attach required safety clips, resulting in a fractured arm and hospitalization. The CNAs involved did not receive updated training on the use of mechanical lifts, contributing to the accident. Resident 36, diagnosed with Parkinson's disease and at risk for falls, experienced multiple falls due to inadequate supervision and failure to implement care plan interventions. Observations revealed that the resident's wheelchair was often not within reach or locked, and investigations into the falls lacked critical information such as the timing of the last visual check or toileting assistance. Additionally, the care plan was not updated with new interventions, and neurological checks post-fall were incomplete. Resident 48, with a history of falls and a diagnosis of chemical imbalance affecting the brain, also experienced multiple falls. The care plan was not updated with new interventions following these incidents, despite staff instructions to place fall mats and keep the bed in the lowest position. The facility's failure to update care plans and implement necessary interventions contributed to the continued risk of falls for these residents.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide appropriate pain management for two residents, resulting in unresolved severe pain. Resident 41, who was admitted with a pressure ulcer and chronic pain syndrome, did not receive their prescribed oxycodone for five days due to the facility's failure to order medications in a timely manner. Despite having access to an emergency medication cart, the staff did not obtain the necessary code to access the medication. As a result, Resident 41 experienced severe pain that prevented them from performing usual daily activities, and it took two days after receiving the medication for their pain to return to baseline levels. Similarly, Resident 52, admitted after spinal surgery, did not receive their prescribed oxycodone on the day of admission, despite reporting severe pain. Although the pharmacy authorized the removal of oxycodone from the emergency supply, the staff did not administer the medication, leading to the resident being sent to the emergency room for pain management. There was also a lack of documentation regarding the resident's pain medication and the rationale for not administering it, highlighting a deficiency in the facility's pain management practices.
Failure to Post Accessible and Accurate Staffing Information
Penalty
Summary
The facility failed to ensure that staffing information was posted in a location easily accessible to residents and visitors, and also failed to post accurate and complete staffing information for several days. On 9/23/24, the Direct Care Staff Daily Report was observed to be posted above standing eye level on a wall behind the nurse's station counter, making it difficult to see. On 9/24/24, the report was not filled out for the evening shift, and on 9/26/24, it was posted without any data. A review of the reports from 8/12/24 through 9/26/24 revealed missing census data for the evening shift on 8/31/24 and missing nursing hours for the night shift on 9/16/24. Staff 34, the Staffing Coordinator/Admissions Coordinator, acknowledged the hard-to-see location and the missing data for the identified dates.
Failure to Implement Enhanced Barrier and Transmission-Based Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) and transmission-based precautions for two residents with wounds, placing them at risk for cross-contamination. Resident 3, admitted with rib fractures, was observed with scabs and a wound dressing on the right shin, but their room was not identified for EBP. Staff 25, an LPN, confirmed that Resident 3 was not on the daily list of residents requiring EBP, despite the Director of Nursing Services (DNS) stating that residents with wound care should be on EBP. Resident 9, admitted with a leg fracture, had a sign indicating EBP and droplet precautions, requiring staff to wear a mask and gown. However, Staff 27, a physical therapist, was observed wearing only gloves without a mask or gown. The DNS confirmed the requirement for masks and gowns, but Staff 27 stated they were not notified of the droplet precautions and did not see the sign.
Deficiency in CNA In-Service Training Hours
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistant (CNA) staff received the required 12 hours of in-service training annually, as evidenced by the review of training records for five out of six staff members. Specifically, one CNA hired in May 2018 had only 10 hours and 46 minutes of training documented, while another hired in May 2022 had just five hours and 36 minutes. A CNA hired in August 2023 had no documented training, and two others hired in March 2018 and April 2022 had less than six hours of training each. The Director of Nursing Services (DNS) acknowledged the deficiency, noting that competency evaluations were conducted upon hire and annually, with in-service training provided during staff meetings and through internet-based services. However, the records did not reflect the completion of the required training hours.
Failure to Include Resident's Guardian in Care Planning
Penalty
Summary
The facility failed to ensure that residents were included in the care planning process, specifically for a resident diagnosed with autism who was admitted in July 2022. The resident's responsible party and guardian, identified as a family member, was not consistently invited to care conferences. Documentation revealed that the last recorded care conference involving the guardian was in October 2023. Subsequent notes from May 2023 and July 2024 did not indicate that the guardian was invited or attended any care conferences. The guardian confirmed not being invited to a care conference for a significant period, which was corroborated by the facility's staff list showing a new Social Services Director hired in April 2024. Despite efforts by facility staff to find additional documentation, no evidence was provided to show the guardian's involvement in care planning since October 2023.
Failure to Document and Follow Up on Advance Directives
Penalty
Summary
The facility failed to ensure that residents' current advance directive information was accurately reflected in their clinical records, affecting three out of five sampled residents. Resident 3, who was admitted with rib fractures and was cognitively intact, had a care plan indicating the presence of an advance directive. However, the clinical record did not include a copy of this directive. Despite the resident's confirmation of having an advance directive and the Social Service Director's acknowledgment of the care plan's indication, no follow-up was conducted to obtain the document for the clinical record. Similarly, Resident 45, admitted with diabetes and left-sided weakness, had no advance directive documented in their medical record, nor was there any indication that one was offered or refused. The Social Services Director confirmed the absence of documentation regarding the offering of an advance directive. Resident 51, with chronic obstructive pulmonary disease and a surgical amputation, also lacked an advance directive in their medical chart. Although a facility form indicated that information about an advance directive was provided, there was no follow-up documentation. The Social Services Director acknowledged the lack of follow-up for the advance directive previously offered.
Failure to Notify Resident's Representative of Hospitalization
Penalty
Summary
The facility failed to notify a resident's representative of the resident's hospitalization, which was a deficiency identified during the survey. Resident 33, who was admitted to the facility in April 2023 with a diagnosis of dementia, experienced a change in condition and was transported to the hospital for evaluation and treatment on August 17, 2024. Despite Witness 6 being listed as the first emergency contact for Resident 33, there was no documentation indicating that Witness 6 was informed of the hospitalization. This lack of notification was confirmed during an interview with Witness 6 on September 23, 2024, and further corroborated by the absence of documentation when requested from Staff 24, an LPN, on September 25, 2024.
Failure to Notify Responsible Party of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide written notification regarding a change in Medicare coverage for a resident, identified as Resident 9, who was reviewed for Medicare notification of non-coverage. Resident 9, who was admitted with a diagnosis including a fracture of the left leg, had a BIMS score of 9, indicating moderate cognitive impairment. A Notice of Medicare Non-Coverage (NOMNC) form was signed by Resident 9, but there was no documentation that the responsible party was contacted or informed about the form, the effective date when Medicare would no longer cover skilled nursing services, or the process to appeal the decision. The deficiency was further highlighted during interviews with staff and the resident's family member. The family member, who was the responsible party, stated that the facility did not contact her regarding the NOMNC form, despite being aware of her role. Staff members, including the Social Services Director and Business Office staff, acknowledged that the protocol for cognitively impaired residents was to notify and have the family representative present during the signing of the form. However, the staff failed to review the resident's clinical record to identify the responsible party, leading to the oversight.
Facility Fails to Maintain Safe and Homelike Environment Due to Uneven Floors
Penalty
Summary
The facility failed to maintain a safe and homelike environment for two residents, resulting in an unsafe and unhomelike living condition. Resident 11, who was admitted with vertigo and unsteadiness, reported that the floor in their room was so uneven that furniture would roll across the room. This was confirmed by an observation of a visible slope in the room. Resident 20, admitted with muscle weakness and unsteadiness, also experienced similar issues, requesting blocks under their bed to level it. Staff confirmed the unevenness, noting that the building appeared to have a U shape from the outside. Staff interviews revealed that the maintenance director acknowledged the problem and stated that an external company would be brought in to assess the situation. A CNA expressed concern about the uneven floors, indicating a risk of losing balance. The regional president and nurse confirmed that inspections were conducted and plans were made to move affected residents to other rooms. However, no structural damage was reported at the time of the interviews.
Failure to Protect Resident from Verbal and Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal and physical abuse by staff. Resident 56, who was admitted with diagnoses including kidney disease and diabetes, and had moderate cognitive impairment, was involved in an incident with Staff 15, an agency LPN. On the night shift, Staff 15 reportedly became upset when Resident 56 pushed a bedside table into him. In response, Staff 15 allegedly grabbed the resident's bed covers, pushed down on the resident's chest, and sternly warned the resident not to repeat the action. This incident was later reported by the resident, who expressed fear about mentioning it. Witnesses, including a family member and other staff, corroborated the account of Staff 15's aggressive behavior. Staff 15 admitted to being loud and stern with the resident and expressed anger during the incident. Despite these reports, the facility did not conduct an investigation into the alleged abuse. Staff 3, a regional president, dismissed the incident as non-abusive, citing the resident's cognitive status and lack of self-reported abuse. However, the absence of an investigation and missing documentation of the incident highlight a deficiency in the facility's handling of abuse allegations.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident with moderate cognitive impairment, diagnosed with kidney disease and diabetes, to the State Survey Agency. The incident occurred when an agency LPN, identified as Staff 15, allegedly had a physical altercation with the resident during the night shift. Staff 15 reportedly bragged about the incident, where the resident pushed a bedside table into him, prompting him to grab the resident's bed covers and push down on the resident's chest. The resident expressed fear about the incident, which was later reported to the family. Despite the seriousness of the allegation, there was no documentation indicating that the facility reported the incident to the State Survey Agency. Interviews with staff and family members corroborated the occurrence of the incident, with Staff 15 admitting to being stern and loud with the resident. The facility's administration, including the Director of Nursing Services and regional management, stated that they expected such allegations to be reported to the appropriate authorities, yet this protocol was not followed in this case.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to investigate an allegation of abuse involving a resident with moderate cognitive impairment, diagnosed with kidney disease and diabetes. The incident occurred when an agency LPN reportedly had a negative interaction with the resident, which included the LPN allegedly pushing down on the resident's chest after the resident pushed a bedside table into the LPN. The resident expressed fear about the incident, and the family was notified. Despite the seriousness of the allegation, there was no documentation indicating that the facility conducted an investigation into the matter. Interviews with staff and family members corroborated the occurrence of the incident, with multiple staff members acknowledging the LPN's actions and the resident's reaction. The facility's administration, including the Director of Nursing Services and regional staff, expected such allegations to be reported to the State Survey Agency and law enforcement. However, no investigation was documented, and the facility did not provide any evidence of having addressed the incident appropriately.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update the care plans for three residents, which placed them at risk for unmet care needs. Resident 3, admitted with fractured ribs, was observed with a wound dressing on the right shin, which had been present for at least a month. Despite this, the care plan initiated in July was not revised to address the shin wound. Staff acknowledged the oversight in updating the care plan to include the skin issue. Resident 43, admitted with kidney disease and a left hand contracture, was dependent on staff for assistance with a soft hand roll. However, the care plan initiated in February was not updated to reflect this need for assistance. Similarly, Resident 9, admitted with sepsis and diabetes, was at risk for pressure injuries and had a left ankle wound requiring specific care. The care plan, revised in September, lacked goals or interventions for the ankle wound, and staff acknowledged the failure to update the care plan properly.
Failure to Provide Shaving Care for Resident
Penalty
Summary
The facility failed to provide adequate shaving care for a resident who was unable to perform activities of daily living independently. The resident, admitted in February 2024 with a diagnosis of stroke, was cognitively impaired but able to communicate needs and required assistance for most ADLs. Observations on September 23 and 24, 2024, revealed the resident had long facial hair, despite expressing a preference for no facial hair. A family member confirmed this preference. A CNA stated that residents were typically shaved on shower days but was unsure why the resident had not been shaved, acknowledging that the resident's facial hair had likely not been attended to for several days.
Failure to Provide Care for Skin Injury and Procedure Preparation
Penalty
Summary
The facility failed to provide appropriate care for a non-pressure skin injury and did not adequately prepare a resident for a medical procedure, affecting two residents. Resident 3, who was admitted with heart disease, had a wound on the right shin that was not properly assessed or treated. The wound was observed to have been present for at least a month, with scabs noted on two separate occasions. However, the clinical record lacked documentation of measurements, assessments, or treatment orders for the wound, and the care plan was not updated to address this issue. It was later discovered that the resident's walker caused friction, leading to the injury, and staff adjusted the walker to prevent further harm. Resident 21, admitted with a stroke diagnosis, was not prepared for a scheduled sigmoidoscopy procedure, which required bowel preparation. Despite hospital discharge orders indicating a follow-up with a general surgeon, the resident was transported for the procedure without the necessary preparation, resulting in a delay. The resident had multiple emergency room visits for bleeding, and the lack of preparation for the diagnostic procedure was acknowledged by the Director of Nursing Services. No additional information was provided regarding this concern.
Failure to Provide Treatment for Hand Contractures
Penalty
Summary
The facility failed to provide appropriate treatment for a resident's hand contractures, which was identified during a survey. The resident, admitted in April 2023 with Parkinson's disease, was noted to have contractures in the third and fourth fingers of both hands. Despite the resident's ability to communicate needs and occasional confusion, there was no treatment plan in place to address the contractures. A family member was unaware of any range of motion (ROM) exercises being provided, and the Director of Nursing Services (DNS) confirmed the absence of a treatment plan for the contractures.
Inadequate Catheter Care and Documentation
Penalty
Summary
The facility failed to provide adequate urinary catheter care and incontinent care for a resident with an indwelling catheter, leading to unmet urinary catheter needs and potential risk for urinary tract infections. The resident, who was admitted with diagnoses including retention of urine and acute kidney failure, had a care plan that required catheter care every shift and monitoring for signs of urinary tract infections. However, documentation revealed inconsistencies in catheter changes and monitoring of urine output. On multiple occasions, there was no documentation of urine output, and the resident experienced significant pain due to a clogged catheter, which was not promptly addressed by the staff. The resident was in pain for an extended period, and despite complaints of bladder pain, the staff did not perform a timely assessment or catheter change. The resident's pain was only relieved after a catheter change was performed by a different staff member during the night shift, resulting in a significant release of urine. Interviews with staff indicated a lack of proper assessment and documentation, with one staff member admitting to not remembering performing a bladder scan or assessment for the resident's pain and lack of urine flow. This deficiency highlights a failure in the facility's catheter care protocol and documentation practices.
Failure to Follow Nutritional Care Plan for Resident with Parkinson's
Penalty
Summary
The facility failed to adhere to the nutritional care plan for a resident diagnosed with Parkinson's disease and mental health disorders, who was at nutritional risk and had difficulty swallowing. The resident was admitted in April 2023 and had a care plan that included providing snacks twice daily (BID) to prevent weight loss. However, there was no documentation indicating that the resident received these scheduled snacks. On September 26, 2024, the Director of Nursing Services (DNS) acknowledged that the task for providing snacks was not correctly entered into the system, and the Certified Nursing Assistant (CNA) task list only included meal intake. A CNA confirmed that scheduled snacks should be documented if provided, but this was not done for the resident in question.
Failure to Implement Non-Pharmacological Interventions and Document Medication Rationale
Penalty
Summary
The facility failed to ensure non-pharmacological interventions were provided before administering medications and did not document a rationale for not implementing a gradual dose reduction for a resident with dementia. The resident was admitted with a diagnosis of dementia and was prescribed multiple antidepressants, including venlafaxine, amitriptyline, citalopram, and mirtazapine. A pharmacy consultation recommended tapering and discontinuing citalopram, which was accepted, and suggested a gradual dose reduction for venlafaxine. However, the physician declined the dose reduction for venlafaxine, citing the resident's difficulty in adjusting to their medical condition, without providing a documented rationale. Additionally, the resident was prescribed Ativan PRN for anxiety, which was administered multiple times without documented evidence of behaviors or non-pharmacological interventions being attempted prior to its use. The facility's Director of Nursing Services (DNS) was unable to provide documentation of non-pharmacological interventions being used before administering Ativan on the specified dates, indicating a lack of adherence to the facility's protocol for managing anxiety with non-pharmacological methods before resorting to medication.
Failure to Obtain Blood Sample for Laboratory Test
Penalty
Summary
The facility failed to ensure a blood sample was obtained for a resident who was admitted in April 2023 with a diagnosis of a stroke. According to the Treatment Administration Record (TAR) from July 2024, staff were instructed to obtain a blood sample for blood chemistry on July 10, 2024. However, the resident's record did not contain the blood chemistry results. On September 25, 2024, a request was made to the Director of Nursing Services (DNS) and a Licensed Practical Nurse (LPN) to provide the laboratory results, but no additional information was provided. This failure placed residents at risk for delayed treatment.
Failure to Offer Dental Appointment
Penalty
Summary
The facility failed to ensure a resident was offered a dental appointment, which was identified as a deficiency. Resident 3, who was admitted in July 2024 with rib fractures, was noted to have missing, broken, or decaying teeth according to a nutritional assessment. Despite being cognitively intact and initially assessed with no dental issues, the resident later reported having cavities and missing bottom front teeth. The resident stated that the facility did not inquire about scheduling a dental appointment. Staff 4, the Social Service Director, was not informed of the resident's dental concerns, and Staff 2, the DNS, acknowledged that although dental issues were identified, there was no follow-up with the resident.
Inappropriate Antibiotic Use and Monitoring
Penalty
Summary
The facility failed to ensure antibiotics were used appropriately and to monitor antibiotic usage for a resident with a urinary catheter or UTI. The resident, who was admitted with a chemical imbalance affecting the brain and a history of falls, experienced two falls and was sent to the hospital, returning with a UTI diagnosis. A urine analysis showed cloudy urine with bacteria, but no urine culture was initially conducted to determine the appropriate antibiotic. The resident was prescribed Cephalexin, an antibiotic, without confirmation of its effectiveness against the bacteria. Subsequent urine culture results revealed that the bacteria were resistant to Cephalexin, and Meropenem was the only effective antibiotic. Despite this, Cephalexin was not discontinued when Meropenem was started, leading to both antibiotics being administered simultaneously. The Director of Nursing Services acknowledged the inappropriate administration of Cephalexin without proper indication and the failure to discontinue it when Meropenem was initiated.
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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