Milton Freewater Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Milton Freewater, Oregon.
- Location
- 120 Elzora Street, Milton Freewater, Oregon 97862
- CMS Provider Number
- 385161
- Inspections on file
- 23
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Milton Freewater Health & Rehabilitation Center during CMS and state inspections, most recent first.
A deficiency was cited when a facility area was not kept free from accident hazards and adequate supervision was not provided to prevent accidents. The report highlights insufficient environmental safety measures and inadequate supervision protocols.
A resident with a history of aggressive behavior physically assaulted another resident by throwing a beverage bottle, resulting in a facial injury. The incident occurred while staff were occupied elsewhere, and prior care plan interventions for the aggressive resident were not effectively implemented, leading to harm.
A resident with severe cognitive impairment and total dependence for transfers developed significant swelling and bruising on the chest and abdomen after a transfer incident. Although a nurse notified facility leadership about the injury, no Facility Reported Incident (FRI) was submitted to the State Survey Agency as required, and the injury was not reported within mandated timelines.
A resident did not receive treatment and care in accordance with physician orders and their personal preferences and goals, resulting in a failure to meet the resident's individualized care plan.
The facility experienced significant staffing shortages, particularly during evening and night shifts, resulting in unmet resident needs and delayed care. Many residents required extensive assistance, and observations showed long periods without CNA presence. Residents reported long wait times for call light responses and pain medication, while staff confirmed the impact of low staffing on care quality. The DNS and Administrator acknowledged the issue, noting inadequate CNA coverage across multiple shifts.
Two residents with aggressive behaviors engaged in physical altercations due to ineffective intervention by the facility. Despite care plans addressing their aggression, incidents occurred where one resident disturbed another's belongings, leading to physical abuse. Staff witnessed these events, confirming the need for immediate intervention.
A resident with major depression and repeated falls was not involved in their care planning process, as no care conference was held since late last year. Despite updates to the care plan, the resident expressed dissatisfaction with the lack of involvement. Staff cited difficulties in organizing care conferences due to staffing changes, acknowledging the resident's absence from the process.
A facility failed to accurately assess a resident for falls. The resident, admitted with dementia, had a discrepancy in their fall history. The March 2024 Quarterly MDS indicated a fall with major injury, but the DNS later confirmed no falls had occurred since the previous assessment, revealing an inaccuracy in the MDS documentation.
The facility failed to provide baseline care plans to three residents within 48 hours of admission, as required. A resident with dementia, another with a compression fracture, and a third with depression did not receive written summaries of their care plans. Staff interviews revealed a lack of awareness and a systemic issue in ensuring care plans were communicated to residents.
A resident with major depression and repeated falls was not assisted in accessing vision care services, despite a physician's order for an eye examination due to visual changes. The resident's health record lacked evidence of any discussion, scheduling, or completion of the examination. Observations showed the resident was not wearing glasses, and the resident reported requesting them months ago without follow-up. The DNS confirmed the absence of documentation regarding the eye examination.
A resident with age-related debility was not walked by staff as required by their Walk Daily Program after being discharged from PT services. Despite the program's inclusion in the resident's care plan, observations and staff interviews confirmed the resident was not walked, with staff citing workload as a barrier. The resident expressed concern about losing mobility due to this inaction.
Two residents in the facility did not have their medication administration documented on two occasions, despite the medications reportedly being given. A nurse, distracted during shift changes, failed to record the administration of levothyroxine for a resident with hypothyroidism and Protonix for a resident with a stomach ulcer, as confirmed by the DNS.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific hazards, the nature of the supervision lapse, or information about the residents involved were provided in the report.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse when one resident physically assaulted another. Resident 10, who had a history of stroke, dysphagia, and documented behavioral issues including verbal and physical aggression, threw a beverage bottle at Resident 11, striking them in the face and causing a small cut on the bridge of the nose. At the time of the incident, all staff were reported to be in resident rooms providing care to other residents, leaving the area unsupervised. Resident 10's care plan included interventions such as providing distractions and monitoring the resident at all times during meals due to their aggressive behaviors, but these interventions were not effectively implemented at the time of the incident. Resident 11, who had no cognitive impairment or behavioral issues, was injured as a result of the altercation. Staff interviews confirmed that Resident 10 had a pattern of aggressive behavior, including previous altercations with Resident 11 and other residents, as well as incidents of physical aggression toward staff. Documentation showed that Resident 10 had initiated several incidents with other residents and staff in the months leading up to the event, but no physical harm had been documented until this incident. The facility's failure to adequately supervise and implement care plan interventions for Resident 10 resulted in harm to Resident 11.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the appropriate State agency within the required state-mandated timelines for one resident. The resident, who had severe cognitive impairment, was completely dependent for transfers and required a two-person assist with a Hoyer sling. The resident was admitted with diagnoses including acute post-hemorrhagic anemia and dysphagia. On a specific date, a nurse observed that the resident's left breast was swollen to three times the size of the right, was engorged, hard to palpate, and had a firm lump, along with bruising on the left side of the abdomen. The nurse was informed that the resident had screamed during a transfer with a sit-to-stand device, and the incident was reported to the evening shift nurse. The nurse who discovered the injury communicated the findings to the facility's administrator and director of nursing, believing the injury should be reported. Despite this, no Facility Reported Incident (FRI) was submitted to the State Survey Agency regarding the injury. Public complaints were later received by the State Survey Agency, indicating that the resident had significant bruising and swelling and was not sent to the hospital for several days after the injuries became apparent. Upon review, facility leadership confirmed that the injury of unknown origin was not reported as required.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
A deficiency was identified when appropriate treatment and care were not provided according to physician orders, as well as the resident's preferences and goals. The report notes a failure to ensure that care was delivered in alignment with the established plan, which is required to meet the individual needs and wishes of the resident. This lapse resulted in the resident not receiving care as intended, based on their documented preferences and medical orders.
Staffing Shortages Lead to Unmet Resident Needs
Penalty
Summary
The facility failed to ensure sufficient nursing staff was available to meet the needs of its residents, as observed and reported during a survey. The facility had a census of 26 residents, with many requiring extensive assistance for daily activities such as transfers, bathing, toileting, and dressing. Observations revealed that there were times when no CNA staff were present in the hallways for up to 30 minutes. Residents reported long wait times for call light responses, with some waiting up to 30 minutes for assistance with incontinence care and others waiting over an hour for pain medication. Staff interviews confirmed that staffing shortages were a persistent issue, particularly during evening and night shifts, leading to unmet care needs and delayed medication administration. Residents and staff expressed concerns about the impact of staffing shortages on care quality. One resident reported crying due to long wait times for assistance, while another resident stopped using the call light due to delays. Staff members indicated that high-acuity residents, including those with dementia and behavioral health needs, were not adequately monitored, leading to increased falls and resident distress. The facility's DNS and Administrator acknowledged the staffing issues, noting that multiple shifts lacked adequate CNA coverage, which was mentally draining for staff and resulted in incomplete resident care.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by incidents involving two residents with aggressive behaviors. Resident 7, diagnosed with dementia and behavioral disturbances, and Resident 17, with hemiplegia and normal cognitive function, both exhibited physical and verbal aggression. Their care plans included interventions to manage these behaviors, but these were not effectively implemented. On two separate occasions, Resident 7 disturbed Resident 17's personal items, leading to physical altercations where both residents struck each other. Staff members witnessed these incidents, confirming the physical abuse between the residents. The first incident occurred when Resident 7 disturbed Resident 17's belongings, resulting in Resident 17 punching Resident 7. The second incident involved Resident 17 yelling at and attempting to strike Resident 7 after finding them near their personal items. Staff members, including a Registered Nurse and a Housekeeping Manager, witnessed these altercations and confirmed the need for immediate intervention to separate the residents. Despite the care plans in place, the facility's failure to effectively intervene and prevent these incidents resulted in a deficiency in protecting residents from abuse.
Failure to Involve Resident in Care Planning
Penalty
Summary
The facility failed to ensure that residents were given the right to participate in the development of their person-centered care plan, as evidenced by the case of a resident admitted in April 2023 with diagnoses including major depression and repeated falls. The resident's health record showed that no care conference had been completed since November 9, 2023, despite updates to the care plan on several occasions in 2024. The resident expressed dissatisfaction with not being involved in the care planning process, noting that other residents participated regularly in care conferences. Staff confirmed that due to changes in staff, it was difficult to organize care conferences, and acknowledged that the resident had not had a care conference since November 2023, although they were expected to be offered at least quarterly.
Inaccurate Fall Assessment for a Resident
Penalty
Summary
The facility failed to accurately assess a resident for falls, which was identified during an interview and record review. The resident, who was admitted in October 2023 with a diagnosis of dementia, had a discrepancy in their fall history. The Quarterly MDS dated March 28, 2024, indicated that the resident had experienced one fall with a major injury since the previous MDS assessment on January 3, 2024. However, on June 24, 2024, the Director of Nursing Services (DNS) stated that the resident had not experienced any falls since the prior assessment, indicating that the fall section of the March 28, 2024, Quarterly MDS was inaccurate.
Failure to Provide Baseline Care Plans to Residents
Penalty
Summary
The facility failed to develop and provide a summary of the baseline care plan for three residents within 48 hours of their admission, as required. Resident 25, admitted with dementia, did not receive a written summary of the baseline care plan, and the Director of Nursing Services (DNS) was unaware if it had been provided. Similarly, Resident 180, admitted with a compression fracture, did not have a baseline care plan developed within the required timeframe, and there was no evidence of resident-centered pain interventions being included or communicated to the resident. Resident 26, admitted with depression, also did not receive a written summary of the baseline care plan. The Divisional Director of Clinical Operations confirmed the absence of documentation indicating that the baseline care plan was discussed or offered to the resident. Furthermore, it was acknowledged that there was no system in place to ensure that baseline care plans were provided to residents and their representatives, highlighting a systemic issue in the facility's admission process.
Failure to Assist Resident with Vision Care Needs
Penalty
Summary
The facility failed to assist a resident in accessing necessary vision care services, which placed the resident at risk for impaired vision. The resident, admitted in April 2023 with diagnoses including major depression and repeated falls, was referred for an eye examination in December 2023 due to visual changes and double vision. However, a review of the resident's health record showed no evidence that an eye examination was discussed, scheduled, or completed. Observations over several days in June 2024 revealed that the resident was not wearing glasses, and the resident reported having requested glasses several months prior without any follow-up. The Director of Nursing Services confirmed the lack of documentation regarding the eye examination in the resident's health record.
Failure to Maintain Resident Mobility Post-PT Discharge
Penalty
Summary
The facility failed to provide appropriate treatment and services to maintain and prevent a potential decrease in mobility for a resident who was reviewed for rehabilitation services. The resident was admitted to the facility with age-related debility and was discharged from physical therapy (PT) services. Despite having a Walk Daily Program task that required the resident to be walked by CNA staff from their room to the nursing station and back every day before lunch, there was no evidence that this was carried out after the resident's discharge from PT services. Observations over several days revealed that the resident was not walked by staff, and interviews with the resident and staff confirmed this lack of action. The resident expressed concern about not walking for at least two weeks, emphasizing the importance of maintaining mobility to avoid becoming weak. Staff members, including a physical therapy assistant and CNAs, acknowledged that the resident was supposed to be walked daily but admitted that this was not happening. One CNA mentioned the inability to walk the resident due to the high number of residents assigned to her, and the Director of Nursing Services confirmed that the Walk Daily Program was not being completed.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to ensure accurate medical records for two residents, leading to a risk of inaccurate treatment. Resident 6, diagnosed with hypothyroidism, was prescribed levothyroxine to be administered daily before breakfast. However, the Medication Administration Record (MAR) for May 2024 showed no documentation of the medication being given on two specific days. The Director of Nursing Services (DNS) confirmed that the nurse responsible was distracted during shift changes and did not document the administration, although the medication was reportedly given. Similarly, Resident 10, with a diagnosis of a stomach ulcer, was prescribed Protonix to be taken daily before meals. The MAR for May 2024 also lacked documentation for the same two days as Resident 6. The DNS stated that the same nurse was involved and failed to document the administration due to distractions during shift changes, despite the medication being administered.
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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