Marquis Mill Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Portland, Oregon.
- Location
- 1475 Se 100th Avenue, Portland, Oregon 97216
- CMS Provider Number
- 385214
- Inspections on file
- 17
- Latest survey
- February 3, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Marquis Mill Park during CMS and state inspections, most recent first.
During a COVID-19 outbreak, a facility failed to follow proper infection control practices, with staff not adhering to PPE protocols and not disinfecting shared medical equipment. Observations showed staff improperly handling PPE and sharing face shields, increasing the risk of cross-contamination. Interviews revealed confusion among staff regarding PPE use, contributing to the deficiency.
The facility inaccurately coded the MDS for two residents, one regarding dental status and the other discharge location. A resident was incorrectly noted as having natural teeth despite being edentulous, and another was wrongly coded as hospitalized instead of discharged home. These errors were confirmed by staff and could lead to unmet care needs.
A resident with respiratory failure required assistance with hearing aids, but the facility failed to include this in the care plan. Family members found the aids uncharged, and staff confirmed the absence of guidance in the care plan, leading to communication barriers.
A facility failed to ensure timely podiatry care for a resident with diabetes and onychomycosis. Despite physician orders for podiatry care in October, no follow-up was made after a message was left in November. By January, the resident had a foot wound and was unsure about the need for podiatry care, with staff confirming no further scheduling efforts had been made.
A facility failed to provide trauma-informed care to a resident with PTSD, as required by their policy. Despite the resident's admission records indicating PTSD, staff were unaware of the diagnosis and did not follow up with the resident, family, or providers. The resident expressed that staff did not inquire about their trauma history, and staff interviews confirmed a lack of awareness and action regarding the resident's PTSD.
A resident with type 2 diabetes mellitus received insulin without proper priming of the insulin pens, as required by the manufacturer's instructions. An LPN administered insulin lispro and insulin glargine without performing the necessary safety steps, resulting in a medication administration error rate of 6.9%. The LPN was unaware of the priming requirement, and the DNS confirmed that staff are expected to follow these instructions.
A facility failed to provide necessary behavioral health services and develop an individualized care plan for a resident with adjustment disorder and depression following an amputation. Despite the resident's openness to non-pharmacological interventions, no psychosocial support was offered, and staff were unsure how to address the resident's emotional needs.
Inadequate Infection Control Practices During COVID-19 Outbreak
Penalty
Summary
The facility failed to adhere to proper infection control practices during a COVID-19 outbreak, affecting two of the four halls reviewed. Observations revealed that staff did not consistently follow the CDC's guidelines for Transmission-Based Precautions. For instance, a CNA was observed exiting a room with a respirator and goggles improperly handled, failing to perform hand hygiene before donning a new respirator. Another LPN entered a room without the necessary eye protection and did not change the respirator after exiting a COVID-19 positive room, indicating a lack of understanding of the required PPE protocols. Further observations highlighted that staff were not disinfecting shared medical equipment between uses, increasing the risk of cross-contamination. A CNA was seen using a blood pressure cuff, stethoscope, thermometer, and oximeter on multiple residents without proper disinfection. Additionally, face shields were improperly stored and shared among staff, contrary to the facility's policy that each TBP room should have dedicated equipment. Interviews with staff revealed confusion and non-compliance with PPE protocols. Some staff members believed it was acceptable to store used face shields with clean PPE or to reuse respirators across different rooms. The facility's DNS and DNS in training acknowledged these practices were against the expected protocols and recognized the risk of contamination and infection spread due to these lapses. The facility's first COVID-19 case was identified earlier in the month, underscoring the urgency of adhering to infection control measures.
Removal Plan
- Immediate staff training was initiated by the DNS and Administrator on COVID transmission protocols, proper use of PPE (donning, doffing and reuse), storage and handling of PPE, disinfecting and use of equipment.
- Staff who received training included CNAs, nurses, housekeeping, laundry, maintenance, administrative staff, agency staff and contracted staff.
- Staff training was done immediately for all staff in the facility then at each shift change.
- Documentation of training would include a sign in sheet and a PPE competency validation form.
- Continued training would be conducted at each shift change and/or 1:1 until all staff received training.
- For staff who were on leave, training would be provided prior to returning to work.
- Facility will have a quality assurance meeting with the committee (Medical Director, Infection Preventionist, DNS, Administrator and other interdisciplinary members) to review policies and procedures on TBP and COVID-19 precautions, including proper use of PPE, storage and equipment use.
- DNS and Infection Preventionist will conduct visual audits every shift to ensure continued compliance with COVID and TBP requirements.
- Audits will be reviewed by the quality assurance team to ensure ongoing compliance.
Inaccurate MDS Coding for Dental and Discharge Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents, leading to potential risks for unmet care needs. Resident 6, admitted with kidney failure, was inaccurately coded as having natural teeth on the Admission MDS, despite being edentulous and using dentures. This discrepancy was confirmed by staff observations and interviews, revealing that the resident had been without teeth for over a decade. The error in coding was acknowledged by the facility's staff, indicating a lapse in the accurate assessment of the resident's dental status. Similarly, Resident 65, admitted with a urinary tract infection, was incorrectly coded as hospitalized on the Discharge MDS, although the resident was discharged home. This error was confirmed upon review of the resident's health record by the Director of Nursing Services (DNS). The inaccurate coding of the discharge location highlights a failure in ensuring the MDS accurately reflected the resident's discharge status, which could lead to miscommunication and potential care planning issues.
Failure to Implement Care Plan for Hearing Aids
Penalty
Summary
The facility failed to develop and implement a care plan for a resident's use of hearing aids, which was necessary for effective communication and hearing. The resident, admitted with a diagnosis of respiratory failure, required assistance with charging their hearing aids at night. However, the care plan did not include any information or instructions regarding the management of the hearing aids. This oversight was confirmed through interviews and observations, where it was noted that the hearing aids were often left in the resident's ears overnight and were not charged properly. Family members and staff interviews revealed that the resident's hearing aids were not being managed according to any documented plan, leading to communication barriers. The family member reported finding the hearing aids still in the resident's ears during morning visits, and staff confirmed the absence of guidance in the care plan. Observations showed that the hearing aids were not charged, as indicated by the blinking green light on the charging station. The Director of Nursing Services confirmed the lack of a care plan addressing the resident's hearing aid needs.
Failure to Provide Timely Podiatry Care
Penalty
Summary
The facility failed to provide appropriate foot care for a resident with diabetes and onychomycosis, as evidenced by the lack of follow-up on a podiatry appointment. The resident was admitted in August 2024 and was cognitively intact. Physician orders from October 2024 indicated the need for podiatry care, but after a message was left with the podiatrist in November 2024, no further efforts were made to schedule the appointment. By January 2025, the resident had a wound on their right foot and was unsure about the need for podiatry care. Staff confirmed that no follow-up actions had been taken since November 2024, despite the continued need for the resident to see a podiatrist.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care to a resident who was a trauma survivor, as required by their Trauma Informed Care Policy. The policy mandates that nursing staff, social services, and the attending physician identify individuals with a history of trauma during the initial assessment and develop a person-centered care plan. However, despite the resident's admission records indicating an active diagnosis of PTSD, there was no evidence in the clinical record that staff were aware of this diagnosis or attempted to follow up with the resident, family members, or medical providers regarding the resident's PTSD. Observations and interviews revealed that the resident tearfully recounted experiences of extreme violence and expressed that facility staff did not inquire about their trauma history. Staff members, including CNAs and social services directors, were unaware of the resident's PTSD diagnosis and did not reapproach the resident or reach out to family or providers for additional information. The Director of Nursing Services stated that residents with a PTSD diagnosis should have a related care plan and that staff should contact family members if residents decline to discuss their trauma, which was not done in this case.
Medication Administration Error Due to Improper Insulin Pen Priming
Penalty
Summary
The facility failed to maintain a medication administration error rate of less than 5%, resulting in a 6.9% error rate. This was identified during an observation of medication administration for a resident with type 2 diabetes mellitus. The resident's physician orders included insulin lispro and insulin glargine, both of which require specific safety steps for priming before administration. However, during the medication administration, the LPN did not perform the necessary priming steps as outlined in the manufacturer's instructions for both insulin pens. The LPN was observed dialing the dose knob to the required units for both insulin lispro and insulin glargine without priming the pens. Upon inquiry, the LPN admitted to being unaware of the priming requirement and acknowledged not performing the safety steps. The Director of Nursing Services was informed of the oversight and stated that staff are expected to follow the manufacturer's instructions for priming insulin pens before administration.
Failure to Address Resident's Behavioral and Emotional Needs
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident diagnosed with adjustment disorder with anxiety and depressed mood following a surgical amputation. The resident, who was admitted in December 2024, expressed feelings of depression and anxiety related to the loss of a limb. Despite these expressions and a documented increase in depressive symptoms, the facility did not offer any behavioral health services, develop an individualized care plan, or conduct ongoing monitoring of the resident's mood to address their emotional and psychosocial needs. Observations and interviews revealed that the resident was open to non-pharmacological psychosocial interventions, such as counseling, but reported that no such support was offered by the facility. A family member corroborated the lack of mood support, and a CNA noted the resident's sadness but was unsure of the cause or how to address it. The Social Services Director acknowledged the resident's depression but did not recall offering any psychosocial support, indicating a lapse in the facility's responsibility to address the resident's behavioral and emotional needs.
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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