Life Care Center Of Mcminnville
Inspection history, citations, penalties and survey trends for this long-term care facility in Mcminnville, Oregon.
- Location
- 1309 Ne 27th Street, Mcminnville, Oregon 97128
- CMS Provider Number
- 385171
- Inspections on file
- 26
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Life Care Center Of Mcminnville during CMS and state inspections, most recent first.
Three residents discharged from the facility did not have complete discharge summaries. The documentation for each lacked essential information such as home instructions, recapitulation of the stay, and, in one case, the name of the home health provider. The DNS confirmed these assessments were not thoroughly completed.
A resident with a colostomy and malnutrition was admitted with an abdominal wound, but the facility did not complete weekly wound assessments despite ongoing symptoms of redness, inflammation, and worsening skin breakdown. Staff confirmed that no wound assessments were performed during the resident's stay.
A resident with a colostomy and multiple chronic conditions experienced ongoing leakage from the ostomy site, resulting in severe skin breakdown and pain. Despite frequent wound care by staff and repeated reports of the issue, physician documentation and assessment did not address the skin condition, leading to the resident's hospitalization for extensive skin damage. The deficiency was due to inadequate physician supervision and failure to evaluate the effectiveness of wound care treatments.
A survey revealed a 23% medication error rate in an LTC facility, with errors in dosage and timing for residents' medications. One resident received incorrect doses of duloxetine and Eliquis, and another was given the wrong dose of sertraline. Staff acknowledged the errors, but no further information was provided by the DNS.
A resident with left-sided hemiparesis required assistance with ADL care, including fingernail care. Despite the care plan indicating the need for assistance, the resident was observed with long fingernails and reported requesting nail trimming, which was not provided. A CNA confirmed that nail care was offered on shower days and acknowledged the resident's dependency on staff for nail care. The DNS also observed the resident's long fingernails and confirmed that nail care had not been completed.
A resident with left-sided hemiparesis following a stroke did not receive a restorative program to prevent decline in range of motion after being discharged from therapy. Despite expressing a desire to participate in such a program, the facility did not offer restorative services, and staff acknowledged the resident would have benefited from them.
A facility failed to provide appropriate dialysis care for a resident by not completing required Pre/Post Dialysis Communication Forms and neglecting to check the resident's dialysis access site daily as per the care plan. The forms were not completed multiple times over several months, and there was no documentation of the required daily checks of the resident's chest wall dialysis access site. Staff confirmed these oversights.
The facility failed to address pharmacy recommendations for two residents, leading to a deficiency in medication management. One resident's haloperidol dose reduction was delayed by 13 days, while another resident's Eliquis order was not updated timely. The DNS acknowledged the lack of a system to ensure timely implementation of pharmacy recommendations.
The facility did not promptly address concerns raised in Resident Council meetings for two out of three months reviewed, risking unresolved quality of life and care issues. Despite policy requirements for prompt action and follow-up, there was no response to issues such as call light accessibility, dietary needs, and room cleanliness. The Activities Director distributed meeting notes to department heads, but no responses were received, contrary to the Administrator's expectations for timely feedback.
Incomplete Discharge Summaries for Discharged Residents
Penalty
Summary
The facility failed to complete thorough discharge summaries for three residents who were discharged during the review period. For one resident admitted with a femur fracture and discharged home with home health services, the discharge summary did not specify the home health company, lacked post-discharge instructions, and omitted a recapitulation of the resident's stay. Another resident admitted with respiratory failure and discharged home did not have home instructions or a recapitulation of their stay included in the discharge summary. Similarly, a third resident admitted with anemia and discharged home was missing home instructions and a recapitulation of their stay in the discharge summary. In each case, the Director of Nursing Services confirmed that the discharge summary information assessments were not completed thoroughly.
Failure to Assess and Document Worsening Abdominal Wound
Penalty
Summary
The facility failed to assess and document a skin wound for a resident with a colostomy and malnutrition, who was admitted with an abdominal ostomy site showing erythema and skin breakdown. Although the hospital history and physical noted the wound, the facility's admission skin assessment did not indicate any abdominal wounds. Progress notes over several days described the resident's abdominal skin as red, inflamed, excoriated, blistered, and tender, with constant drainage and irretractable pain. Despite these ongoing symptoms and the worsening condition, no weekly wound assessments were completed from admission through the resident's transfer to the hospital and subsequent return. Facility staff confirmed that no wound assessments were performed during this period.
Failure to Ensure Physician Oversight of Wound Care for Resident with Colostomy
Penalty
Summary
The facility failed to ensure that a physician adequately supervised a resident's medical care and evaluated the effectiveness of wound care treatments for a resident with a colostomy and multiple chronic conditions, including atrial fibrillation and malnutrition. Upon admission, the resident had an abdominal ostomy site with surrounding erythema and skin breakdown. Care plans were in place to protect the skin from ostomy drainage, but physician documentation did not address the leaking ostomy or the condition of the surrounding skin. Progress notes over several days described persistent leakage, red and inflamed skin, and worsening excoriation, with staff frequently reporting the issue and providing wound care, but without effective resolution or physician intervention regarding the skin condition. The resident's condition deteriorated, resulting in extensive skin breakdown, maceration, and severe pain, ultimately requiring hospital transfer for evaluation and treatment. Hospital records confirmed significant skin damage related to ostomy leakage. Upon readmission, physician notes continued to omit assessment of the skin surrounding the colostomy site. Interviews with staff confirmed ongoing issues with the colostomy bag and skin integrity, and the physician acknowledged focusing on other medical concerns and not assessing the abdominal wound. The lack of physician oversight and failure to address the persistent skin issues led to the deficiency.
Medication Errors Exceeding 5% in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 23% error rate. This was observed during a survey where six errors were identified in 26 opportunities. The errors involved incorrect dosages and administration times for medications prescribed to residents. For instance, Resident 152, who was admitted with heart failure, GERD, and fibromyalgia, was given incorrect doses of duloxetine and Eliquis, and omeprazole was administered after breakfast instead of before. Additionally, Tylenol was administered late, and cetirizine was prepared instead of the prescribed loratadine. Another incident involved Resident 10, who was admitted with major depressive disorder. The resident was prescribed sertraline 100 mg daily, but Staff 3 prepared only 50 mg. These errors were identified by a State Surveyor, and the staff involved acknowledged the discrepancies. The Director of Nursing Services (DNS) was informed of these findings but provided no additional information.
Failure to Provide Necessary Fingernail Care
Penalty
Summary
The facility failed to provide necessary assistance with fingernail care for a resident who was unable to perform this activity independently. The resident, who was admitted in 2024 with a diagnosis of stroke and left-sided hemiparesis, required assistance with activities of daily living (ADL) due to left-sided weakness. According to the care plan dated August 7, 2024, the resident needed help with ADL care. Although the treatment administration record (TAR) indicated that the resident received nail care on October 31, 2024, an observation on November 4, 2024, revealed that the resident had long fingernails and had requested nail trimming, which was not provided by the staff. On November 6, 2024, a CNA confirmed that nail care was typically offered on shower days and acknowledged the resident's dependency on staff for nail care, noting the resident's long fingernails. The Director of Nursing Services (DNS) also observed the resident's long fingernails and confirmed that nail care had not been completed.
Failure to Provide Restorative Program for Resident with Hemiparesis
Penalty
Summary
The facility failed to provide a restorative program to prevent decline in range of motion for a resident who was admitted with diagnoses including stroke and left-sided hemiparesis. The resident's care plan indicated left-sided weakness and impaired mobility, requiring assistance with activities of daily living. Despite making consistent progress in physical and occupational therapy, the resident's upper extremity hemiparesis did not improve, and the therapy discharge summaries noted that a restorative program was not indicated at that time. However, the resident expressed a desire to participate in a restorative program and reported not receiving range of motion exercises for their hand. Staff confirmed that the resident was a good candidate for restorative services post-therapy discharge due to the stroke and difficulty using the left hand. The facility did not offer a restorative program, and staff were unsure of when such services were last provided, acknowledging that the resident would have benefited from them.
Failure to Provide Appropriate Dialysis Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident, identified as Resident 30, who required dialysis services. The facility's Hemodialysis Offsite Policy required staff to complete a Pre/Post Dialysis Communication Form to be sent with the resident to the dialysis clinic and completed upon their return. However, a review of these forms from July 2024 through October 2024 revealed multiple instances where the forms were not completed, specifically five times in July, ten times in August, ten times in September, and ten times in October. Staff 4, an LPN, confirmed that the forms were not consistently completed, and Staff 2, the DNS, acknowledged the failure to complete the forms on the identified dates. Additionally, the care plan for Resident 30 indicated that the resident had a right chest wall dialysis access site that required daily checks. However, there was no evidence in the medical record that these checks were performed. Resident 30 reported that staff did not assess the dialysis site after returning from dialysis. Staff 2 confirmed that the nursing staff were supposed to check the resident's chest and document it on the Treatment Administration Record (TAR), but acknowledged that there was no documentation of these checks in the TAR or the resident's medical record.
Failure to Address Pharmacy Recommendations for Two Residents
Penalty
Summary
The facility failed to ensure that pharmacist recommendations were considered for two residents, leading to a deficiency in medication management. Resident 14, who was admitted with a diagnosis of delusional disorder, was receiving haloperidol for psychosis related to metabolic encephalopathy and hallucinations. A pharmacy recommendation on 9/26/24 suggested a gradual dose reduction of haloperidol, as there were no episodes of delusions or hallucinations in the last three months. Although the physician signed off on the recommendation, it was not noted by the Director of Nursing Services (DNS) until 10/8/24, indicating a delay of 13 days in addressing the recommendation. Staff 2 acknowledged that the facility lacked a system to ensure timely addressing of pharmacy recommendations. Similarly, Resident 28, admitted with atrial fibrillation, had a pharmacy recommendation on 10/16/24 to update the medication order for Eliquis, which included outdated instructions related to a previous course of Paxlovid. The DNS did not recall receiving this recommendation and had to retrieve it online on 11/8/24, indicating that it had not been addressed in a timely manner. This oversight highlights the facility's failure to have an effective system in place to manage and implement pharmacy recommendations, potentially placing residents at risk for unnecessary medication.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to promptly respond to concerns raised during Resident Council meetings for two out of three months reviewed, which placed residents at risk for unresolved quality of life and care issues. The facility's policy, revised on 9/27/23, mandates that the facility must act promptly on recommendations from resident groups concerning care and life in the facility. The Activities Director is responsible for facilitating follow-up on suggestions and reporting results at the next meeting, with each Department Director required to fill out a comment form before the next meeting. However, the review of Resident Council Minutes from July to September 2024 revealed that there was no follow-up on residents' concerns and recommendations after the meetings held on 7/10/24 and 8/7/24. During the 7/10/24 meeting, residents expressed concerns about doors being closed without permission, call lights not being within reach, squeaking beds, and a lack of communication. In the 8/7/24 meeting, issues raised included the need for a cooler for food items, diet reports not being followed, rooms not being cleaned daily, and delays in call lights and medications. The 9/11/24 meeting also highlighted concerns about dietary preferences, diabetic options, clothing misplacement, and trash removal, with no follow-up from dietary and maintenance departments. Staff 3, the Activities Director, stated that she distributed meeting notes to department heads but did not receive responses. The Administrator, Staff 1, expected department managers to respond within seven to ten days, which did not occur.
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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