Marquis Centennial Post Acute Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Portland, Oregon.
- Location
- 725 Se 202nd Avenue, Portland, Oregon 97233
- CMS Provider Number
- 385183
- Inspections on file
- 20
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Marquis Centennial Post Acute Rehab during CMS and state inspections, most recent first.
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.
Surveyors found widespread environmental deficiencies, including dirty and dusty fixtures, vents, and fans in common areas, as well as unkept and unsanitary shower rooms with mold-like substances, rust, and damaged fixtures. A resident with pneumonia expressed concerns about the shower room's cleanliness and safety, and another resident was bothered by scratches and missing paint in their room. Facility staff acknowledged these issues during the survey.
Staff failed to label and discard food items appropriately in a unit refrigerator, leaving undated and expired food present. Housekeeping staff were unaware of food storage policies, and scheduled cleaning was missed. In the kitchen, dietary aides stored an ice scoop directly in the ice and used it without gloves, contrary to expected procedures. These actions did not meet professional standards for food safety.
Staff did not follow infection control protocols for two residents, including not using PPE during wound care for a resident with a draining leg wound and allowing another resident's urinary catheter tubing to rest on the floor. These actions were inconsistent with facility policy and CDC guidelines for enhanced barrier precautions.
A resident with dysphagia and cognitive impairment was provided with thin liquids instead of the prescribed mildly thickened liquids due to the care plan not reflecting the physician's order. Multiple CNAs were unaware of the dietary requirement, and the RNCM confirmed the care plan omission, resulting in the resident receiving inappropriate fluids.
A resident with anxiety disorder and malnutrition reported a broken bed foot board that remained unrepaired for several days. Despite two CNAs being aware of the issue and attempting to reinsert the foot board, maintenance was not notified, and no repair request was submitted. The Maintenance Director stated staff are expected to report such issues electronically.
The facility failed to follow care plans and provide adequate supervision, resulting in falls and injuries for two residents. One resident sustained serious injuries after a CNA allowed them to walk to the bathroom with only a cane, contrary to their care plan. Another resident, with a history of falls, was left unsupervised while awake, leading to multiple falls.
The facility failed to provide a timely Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) for a resident with dementia and emphysema, who had impaired memory and decision-making skills. The notice was given on the last covered day of Medicare Part A services instead of the required 48-hour notice, placing the resident at risk for unknown financial liabilities.
The facility failed to conduct a new and accurate Level I PASARR for a resident with serious mental illness diagnoses and did not complete a referral for a Level II PASARR. The resident exhibited significant behavioral issues, and the administrator acknowledged the incorrect coding and the need for a referral.
The facility failed to develop a comprehensive care plan for a resident with moderate cognitive impairment and a language barrier. Staff were unaware of a communication binder available to assist in communication, leading to ineffective communication and unmet care needs.
The facility failed to follow physician orders for a resident with heart failure, missing multiple days of required daily weights in April 2024. Staff interviews confirmed that the resident rarely refused to be weighed, but documentation and communication lapses led to the deficiency.
The facility failed to perform post-dialysis assessments on a resident with end-stage renal disease. Despite a physician's order, these assessments were not completed on multiple dates. The resident reported that their vitals and port site were often not checked after dialysis. Staff confirmed that required assessments were not performed or documented.
The facility failed to protect residents from physical abuse, involving multiple incidents where one resident pushed another, causing minor injuries, and another resident physically assaulted a fellow resident in the dining room. Additionally, a resident with severe cognitive impairment punched another resident in the face while she/he was resting in bed. Staff interviews confirmed a history of aggressive behavior and poor safety awareness among the involved residents.
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 Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's physical environment, including a lack of maintenance and cleanliness in common areas and resident spaces. In the dining room, all hanging light fixtures contained dead insects, portable fans were visibly dusty and blowing air toward residents, and floor vents were coated in thick dust, debris, and cobwebs. In the kitchen, a dirty floor fan was operating and blowing air across both clean and dirty areas, including sanitized food containers. A ceiling vent in a hallway was also found with significant dust and cobweb buildup. Facility staff, including the Administrator and Maintenance Director, acknowledged these concerns during the survey. A resident with a recent admission for pneumonia reported concerns about the cleanliness and safety of the shower room, specifically noting a black substance on the floor that staff attempted to clean without success. Observations confirmed the shower room was unkept, with mold-like substances, rust, peeling tiles, a loose drain lid, and a dirty fan. Clean linens were stored on a rusty shelf, and the water handle was loose and difficult to adjust. Another resident's room was observed with scratches and missing paint on the wall, which the resident found bothersome. Staff acknowledged these environmental issues required attention.
Improper Food Labeling and Unsafe Ice Handling Practices
Penalty
Summary
Facility staff failed to ensure proper labeling and timely disposal of food items in one of two unit refrigerators. Observations revealed several undated containers of food, including a meal with a ticket dated ten days prior, and other containers of spaghetti and rice with mixed vegetables that were not labeled. Interviews with staff indicated that housekeeping was responsible for cleaning and discarding old or undated food items every 72 hours, but the designated housekeeper was away, and the last cleaning had occurred a week prior. Housekeeping staff were unaware of the facility's food storage policies, and maintenance staff confirmed the cleaning schedule was not followed as expected. Additionally, during a kitchen tour and meal service observation, a covered container of ice was found with the ice scoop stored inside, directly on the ice. Dietary aides were observed using the scoop without gloves and returning it to the ice container after use. Staff interviews revealed a lack of awareness of proper procedures for storing the ice scoop, and the dietary manager confirmed that staff were expected to store the scoop separately from the ice. These practices did not align with professional standards for safe food storage and handling.
Failure to Implement Infection Control Practices for Wound and Catheter Care
Penalty
Summary
The facility failed to implement proper infection prevention and control practices for two residents with specific care needs. For one resident with a facility-acquired wound behind the left calf, staff did not follow enhanced barrier precautions (EBP) as required by facility policy and CDC guidelines. Despite the presence of a wound with fluid and drainage, staff did not don personal protective equipment (PPE) during high-contact activities such as bathing and wound care. Additionally, there were no signs posted outside the resident's room to indicate the need for EBP, and multiple staff members stated they did not use PPE because they believed the wound was not infected or the drainage was minimal. For another resident with an indwelling urinary catheter, the catheter tubing was repeatedly observed on the floor while the resident was in the activity room. Staff members acknowledged that the tubing should not touch the floor and confirmed the observation, but failed to ensure proper catheter care practices were followed. These lapses in infection control placed both residents at increased risk for infection.
Failure to Implement Physician Order for Thickened Liquids
Penalty
Summary
A deficiency occurred when the facility failed to implement a physician's order for mildly thickened liquids for a resident with dysphagia. The resident, who was cognitively impaired and required mildly thickened liquids per hospital discharge orders, did not have this requirement reflected in the nutrition care plan. Multiple observations showed the resident had access to thin liquids at the bedside, and several CNAs confirmed they were unaware of the thickened liquid order. The RN Case Manager acknowledged that the care plan did not include the physician's order, which led to staff providing thin liquids instead of the prescribed consistency.
Failure to Repair Broken Bed Foot Board
Penalty
Summary
A deficiency was identified when a resident, admitted with generalized anxiety disorder and malnutrition and noted to be cognitively intact, reported that the foot board of their bed was broken and had not been repaired. The issue was first noticed by the resident, who stated the foot board had been broken for several days. Observations confirmed that the foot board was unsecured and could be dislodged when pressure was applied. Two nursing assistants were aware of the broken foot board, having observed it was not secured and attempting to reinsert it, but neither notified maintenance. A review of maintenance work orders showed no request had been submitted for repair, and the Maintenance Director confirmed that staff were expected to report such issues electronically during their shift.
Failure to Follow Care Plans and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure staff followed the care plan related to fall safety and provide sufficient supervision to prevent a fall for two residents. Resident 306, who was admitted with a right leg fracture and right shoulder fracture, required extensive assistance from two or more staff to transfer on and off the toilet. However, on 5/7/23, an agency CNA responded alone to Resident 306's call for assistance and allowed the resident to walk to the bathroom with only a cane, contrary to the care plan. This resulted in Resident 306 falling and sustaining serious injuries, including a left shoulder fracture, a rib fracture, and a periprosthetic fracture involving the left greater trochanter. The facility's internal investigation confirmed that the CNA did not follow the care plan at the time of the fall. Resident 47, admitted with dementia and a history of falls, was also not provided with adequate supervision. The resident's care plan indicated that they should not be left unsupervised in their room while awake due to the risk of self-transfer attempts. Despite this, the resident experienced multiple falls, including one on 4/13/24, where the CNA failed to provide necessary details about care provided prior to the fall. Additionally, on 4/30/24, a CNA left Resident 47 alone in their room while awake, leading to the resident attempting to transfer themselves out of bed. The pressure-sensitive call light did not activate, and the resident was found attempting to stand up independently. Both incidents highlight a failure to adhere to care plans and provide adequate supervision, resulting in falls and injuries. Staff interviews revealed that CNAs were expected to consult care plans and perform frequent checks on high-risk residents, but these protocols were not consistently followed. The deficiencies in supervision and adherence to care plans directly contributed to the accidents involving Residents 306 and 47.
Failure to Provide Timely SNF ABN Notice
Penalty
Summary
The facility failed to provide a written Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) in a timely manner for a resident reviewed for Beneficiary Protection Notification. The resident, who was admitted with diagnoses including dementia and emphysema, had impaired short- and long-term memory and moderately impaired decision-making skills. The resident's last covered day of Medicare Part A services was on 4/1/24, and the facility provided the Notice of Medicare Non-Coverage on the same day. However, the facility should have given a 48-hour notice to inform the resident of the change, as stated by the Administrator. This failure placed the resident at risk for unknown financial liabilities.
Failure to Conduct Accurate PASARR and Referral for Behavioral Services
Penalty
Summary
The facility failed to conduct a new and accurate Level I PASARR when it became aware of indicators of a serious mental illness diagnosis for a resident. The resident, who was admitted in June 2023, had multiple diagnoses including Psychotic Disorder with delusions, Delusional Disorder, Dementia with behaviors, PTSD, Major Depressive Disorder, and anxiety. Despite these diagnoses and documented behavioral concerns such as delusions, physical and verbal aggression, socially inappropriate behaviors, and a history of suicidal behavior, the facility did not complete a correct Level I PASARR or make a referral for a Level II PASARR for behavioral services. Observations and record reviews revealed that the resident exhibited significant behavioral issues, including slamming doors, yelling at others, and making negative statements on multiple occasions. The resident was also observed to self-isolate in their room. The facility's administrator acknowledged that the Level I PASARR was coded incorrectly and that a referral for a Level II PASARR should have been initiated given the resident's diagnoses and behaviors. No additional information was provided to rectify the situation.
Failure to Develop Comprehensive Care Plan for Resident with Language Barrier
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for a resident with moderate cognitive impairment and a language barrier. The resident, who primarily spoke Chinese/Taiwanese/Cantonese, was observed struggling to communicate with staff, who were unaware of the available communication aids. Specifically, a CNA was seen attempting to understand the resident through trial and error, and was unaware of a communication binder with pictures that could assist in communication. This binder was found in the resident's room but was not included in the care plan, leading to ineffective communication and unmet care needs. Further interviews revealed that the staff, including the CNA and RNCM, were not informed about the communication binder, and it was not documented in the resident's care plan. The SSD and Administrator both confirmed that communication aides should be included in care plans to ensure staff are aware of and use them. The lack of inclusion of the communication binder in the care plan resulted in staff being unaware of its existence and not utilizing it to aid in communication with the resident.
Failure to Follow Physician Orders for Daily Weights
Penalty
Summary
The facility failed to follow physician orders for a resident diagnosed with heart failure, who was admitted in June 2023. The physician's orders required daily weights to be obtained for the resident and to notify the physician if the resident gained three pounds in 24 hours or five pounds in a week. However, a review of the resident's weight summary for April 2024 revealed multiple days without recorded weights, specifically on 4/2, 4/3, 4/4, 4/5, 4/8, 4/9, 4/12, 4/17, 4/18, 4/19, 4/20, 4/26, and 4/30. This failure to document weights as ordered placed the resident at risk for unmet needs related to their heart failure condition. Interviews with staff confirmed the deficiency. A CNA stated that the resident was to be weighed daily and rarely refused. An LPN confirmed that the resident was weighed daily due to heart failure and that nurses were expected to document reasons for any missed weights in the resident's progress notes. However, the LPN acknowledged that CNAs did not always inform her when weights were not obtained, leading to missing documentation. The Director of Nursing Services also confirmed that the resident was cooperative with being weighed and that nurses were expected to notify the physician if weights were not obtained, which did not occur as required.
Failure to Perform Post-Dialysis Assessments
Penalty
Summary
The facility failed to perform post-dialysis assessments on a resident with end-stage renal disease. Despite a physician's order requiring nursing staff to assess the resident's vital signs and write a progress note upon their return from dialysis, these assessments were not completed on multiple dates in April 2024. The resident reported that their vitals and port site were often not checked after dialysis. Staff confirmed that post-dialysis assessments, which should include checking respiratory rate, heart rate, blood pressure, and the port site, were not performed or documented as required.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect the residents' right to be free from physical abuse by another resident, affecting two of the five sampled residents. Resident 34, who was admitted with a history of traumatic brain injury and severe cognitive impairment, was involved in multiple incidents with Resident 47, who had dementia with psychotic disturbance and PTSD. On one occasion, Resident 47 pushed Resident 34, causing her/him to fall and sustain minor injuries. Despite staff efforts to keep the residents apart, Resident 34 went outside to the courtyard where Resident 47 was visiting with her/his spouse, leading to the altercation. Staff interviews confirmed that Resident 47 had a history of aggressive behavior and poor safety awareness, which contributed to the incident. In another incident, Resident 47 physically assaulted Resident 34 in the dining room by grabbing her/him around the neck and face. This occurred after Resident 47 accused Resident 34 of being a thief, possibly confusing the voice on the television for Resident 34. Staff members intervened immediately, but Resident 34 sustained red marks on her/his neck and forehead. Staff interviews revealed that Resident 47 had been in a bad mood that day and had a history of aggressive behavior towards other residents. Additionally, Resident 43, who had severe cognitive impairment, punched Resident 29 in the face while she/he was resting in bed. The facility was not aware of the incident until the following day when swelling and discoloration were observed on Resident 29's upper lip. Staff interviews and written statements confirmed that Resident 43 had a history of behavioral disturbances and that the incident was not immediately reported or addressed. The facility acknowledged the findings of the investigation and the failure to protect residents from abuse.
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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