Marquis Plum Ridge Post Acute Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Klamath Falls, Oregon.
- Location
- 1401 Bryant Williams Dr., Klamath Falls, Oregon 97601
- CMS Provider Number
- 385137
- Inspections on file
- 21
- Latest survey
- February 11, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Marquis Plum Ridge Post Acute Rehab during CMS and state inspections, most recent first.
The facility failed to label opened OTC medications on three medication carts, as observed by surveyors. Multiple bottles were found without open date labels, which was acknowledged by a CMA and the DNS, who stated that all medications should be labeled and dated when opened.
The facility failed to maintain proper food temperatures, leading to resident complaints about cold and unpalatable meals. The Dietary Manager and Administrator were aware of these issues, which were confirmed during a resident council meeting and test tray sampling. Multiple residents, including those with medical conditions like diabetes and surgical aftercare, reported receiving cold meals, such as beef stroganoff and breakfast burritos.
A facility failed to provide quarterly Personal Incidental Funds (PIF) statements to the designated representative of a resident with severe cognitive impairment. The resident's family member, who held power of attorney, did not receive any PIF statements, as confirmed by both the family member and the facility's office manager.
The facility failed to assist three residents in formulating advance directives, potentially leading to healthcare decisions that conflict with their wishes. Despite being cognitively intact, these residents were not offered advance directives, and the facility was behind on quarterly Interdisciplinary Care Conferences, contributing to the oversight.
A resident's bank card was misused by a former Activity Assistant, leading to unauthorized ATM withdrawals totaling $3,320. The staff member claimed coercion by an individual she believed to be a family member of the resident. The facility identified the suspect with law enforcement assistance and reimbursed the family.
A resident with PTSD reported feeling verbally abused after being forced to take a shower, contrary to their care plan preferences. The facility's investigation was inadequate, lacking witness statements and a resident interview. Staff involved claimed the resident did not express refusal or distress during the incident, but the resident later reported feeling verbally abused. The administrator acknowledged the investigation's shortcomings.
The facility failed to conduct quarterly care conferences for three residents, leading to a deficiency in care planning. A resident admitted with weakness did not have any quarterly care conferences after March 2024, and another resident with surgical aftercare needs did not have conferences after September 2024. The absence of these conferences was confirmed by both the residents and the facility administrator.
The facility failed to accurately assess and document pressure ulcers for two residents, leading to potential risks of worsening wounds. One resident's Stage 4 ulcer was misclassified due to slough, while another resident's heel ulcer care plan was not followed, with staff unaware of the wound and necessary offloading measures. The DNS and administrator acknowledged these deficiencies.
Failure to Label Opened OTC Medications
Penalty
Summary
The facility failed to ensure proper labeling of biologicals on three out of six medication carts, which was observed during a survey. On January 29, 2025, at 10:59 AM, multiple bottles of over-the-counter (OTC) medications were found opened without open date labels on the front hall medication cart. Additionally, two other medication carts located on the front and back halls were observed to have multiple bottles of OTC medications also lacking open date labels. Staff 17, a Certified Medication Aide (CMA), acknowledged the presence of these unlabeled medications across all three carts. Later, at 11:59 AM, Staff 2, the Director of Nursing Services (DNS), confirmed the observations and acknowledged the issue of multiple OTC medications without open date labels on the bottles. Staff 2 stated that her expectation was for staff to label and date every medication upon opening.
Facility Fails to Maintain Proper Food Temperatures
Penalty
Summary
The facility failed to maintain proper food temperatures for meals served to residents, as observed during a survey. The Dietary Manager and Administrator were aware of ongoing complaints from residents about cold and unpalatable food. During a resident council meeting, nine residents expressed concerns about meals being served cold. A test tray sampled by the survey team revealed that the beef stroganoff was barely warm, noodles were dried out, green beans were cold, and other items like grilled cheese and tater tots were not served at appropriate temperatures. Multiple residents, including those with specific medical conditions such as pressure ulcers, diabetes, and surgical aftercare, reported receiving cold meals. Resident 3, for instance, experienced cold and undercooked food during dinner and lunch observations. Resident 6, who has diabetes, also reported consistently receiving cold meals, including a breakfast burrito. Resident 37, admitted for surgical aftercare, similarly reported cold meals, including a hamburger and beef stroganoff. Resident 23, with a diagnosis of diabetes, and Resident 266, with a hip fracture and depression, also reported receiving cold meals. Resident 23 described the grilled cheese as hard and the beef stroganoff as having a mechanical soft texture that was unpleasant. Resident 266, who is cognitively intact, noted that meals were often cold, including the stroganoff and green beans. The Administrator acknowledged the complaints and stated that food should be served at the appropriate temperature and palatability for all residents.
Failure to Provide Quarterly PIF Statements to Resident's Representative
Penalty
Summary
The facility failed to provide quarterly statements of Personal Incidental Funds (PIF) to the designated representative of a resident with severe cognitive impairment. The resident, admitted in 2013 with diagnoses including a stroke and depression, had a BIMS score of 3, indicating severe cognitive impairment. The resident's family member, who was the designated power of attorney, did not receive any quarterly PIF statements from the facility. This was confirmed during an interview with the family member and the facility's office manager, who acknowledged that the statements should have been generated and sent but were not.
Failure to Assist Residents with Advance Directives
Penalty
Summary
The facility failed to assist residents in formulating advance directives for three of the four sampled residents, which could lead to healthcare decisions conflicting with the residents' wishes. Resident 3, admitted in March 2023 with a diagnosis of weakness, was found to be cognitively intact according to the Annual MDS conducted in March 2024. However, during an Interdisciplinary Care Conference in March 2024, it was noted that Resident 3 did not have an advance directive. The resident expressed on January 27, 2025, that staff had not offered an advance directive and wished to have options reviewed. Staff 26, the Social Service Director, acknowledged the need to review advance directive options during quarterly Interdisciplinary Care Conferences, but Staff 1, the Administrator, admitted that these conferences were behind schedule, and advance directives were not being followed up on. Similarly, Resident 7, admitted in August 2023 with respiratory failure, was also cognitively intact as per the Annual MDS in August 2024. The Interdisciplinary Care Conference in February 2024 revealed the absence of an advance directive for this resident. On January 27, 2025, Resident 7 stated that staff had not offered an advance directive and wanted options reviewed. Resident 37, admitted in February 2023 for surgical aftercare, was cognitively intact according to the Annual MDS in February 2024. The Interdisciplinary Care Conference in September 2024 also showed no advance directive for this resident, who expressed a desire for one on January 28, 2025. The facility's failure to keep up with quarterly Interdisciplinary Care Conferences contributed to the lack of follow-up on advance directives for these residents.
Misappropriation of Resident's Funds by Staff Member
Penalty
Summary
The facility failed to protect a resident from the misappropriation of property, specifically involving the wrongful use of the resident's bank card. The incident involved a resident who was admitted in April 2022 with a diagnosis of cirrhosis of the liver. A public complaint was received alleging that the resident had money stolen from their bank account. An investigation revealed that the resident's bank card was used for unauthorized ATM withdrawals totaling $3,320 over a period of three days. The facility's Business Office Manager was notified of a declined payment, which led to the discovery of the missing funds. Further investigation identified a former Activity Assistant as a suspect, who was later arrested. The staff member claimed to have been coerced by an individual she believed to be a family member of the resident, who threatened her and her family. She admitted to assisting this individual in withdrawing money from an ATM, although she claimed she was unaware it was the resident's account. The facility assisted law enforcement in identifying the suspect and reimbursed the family for the stolen amount.
Inadequate Investigation of Verbal Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an alleged incident of verbal abuse involving a resident with PTSD. The resident, admitted in August 2023 with a diagnosis of respiratory failure, reported feeling verbally abused after being forced to take a shower by a staff member. The resident expressed that being told what to do was a trigger for their PTSD. Despite the resident's care plan indicating a preference for bed baths and that they would request a shower if desired, the staff proceeded with the shower, leading to the resident's distress. The investigation into the incident was inadequate, as it lacked witness statements and did not include an interview with the resident regarding the abuse allegation. Staff involved in the incident reported that the resident did not express refusal or feelings of abuse during the shower. However, the resident later communicated to another staff member that they felt verbally abused and had expressed a desire not to shower. The facility's administrator acknowledged that the investigation was not thorough, as it did not meet the expectations of interviewing the resident and obtaining written and signed witness statements.
Failure to Conduct Quarterly Care Conferences
Penalty
Summary
The facility failed to conduct quarterly care conferences as required for three residents, leading to a deficiency in care planning. Resident 3, admitted in March 2023 with a diagnosis of weakness, did not have any quarterly care conferences after March 2024. This was confirmed by the resident, who expressed concerns about not having had a care conference in months. The facility administrator also confirmed the lack of quarterly care conferences for this resident. Similarly, Resident 7, also admitted in March 2023 with a diagnosis of weakness, did not receive quarterly care conferences after February 2024. The resident expressed similar concerns about the absence of care conferences. Resident 37, admitted in February 2023 for surgical aftercare, did not have quarterly care conferences after September 2024. This lack of regular care conferences was confirmed by both the residents and the facility administrator, indicating a systemic issue in the facility's care planning process.
Failure to Accurately Assess and Follow Care Plans for Pressure Ulcers
Penalty
Summary
The facility failed to accurately assess and document the pressure ulcer status of two residents, leading to potential risks of inaccurate assessment and worsening of wounds. Resident 3 was admitted with a Stage 4 pressure ulcer, but the Wound Evaluation Form inaccurately documented the wound as a Stage 4 when it was actually unstageable due to the presence of slough. This discrepancy was acknowledged by the Director of Nursing Services (DNS), indicating a failure in proper wound assessment and documentation. Resident 31, who was cognitively intact, had a pressure injury on the right heel that required offloading with a pillow or heel boot protector as per the care plan. However, observations revealed that the resident's heel was not offloaded, and several staff members, including CNAs and an LPN, were unaware of the wound and the necessary care plan. The RN Case Manager confirmed the staff's failure to follow the care plan, and the facility's administrator and DNS acknowledged the oversight, highlighting a lack of communication and adherence to care protocols.
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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