Mt. Tabor Health & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Portland, Oregon.
- Location
- 6040 Se Belmont Street, Portland, Oregon 97215
- CMS Provider Number
- 385141
- Inspections on file
- 23
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Mt. Tabor Health & Rehabilitation during CMS and state inspections, most recent first.
A resident with acute kidney failure and dependence on renal dialysis had a care plan specifying thrice-weekly dialysis with arranged transportation, but the facility failed to schedule transportation over a holiday period, leading to missed treatments and lack of documentation for one scheduled session. The receptionist reported being unable to set up transportation, and an LPN confirmed that staff knew transportation needed to be scheduled but the resident still missed a treatment. A family member was contacted by the dialysis center about the resident’s absence, found the resident very sick, and requested transfer to the ER, where dialysis was subsequently completed. The DNS acknowledged that the missed dialysis occurred because transportation had not been scheduled.
A resident with a feeding tube did not receive scheduled tube feeding on time due to an LPN's lack of competency in tube feeding administration. The LPN and Interim DNS were both unsure how to properly connect the feeding tube, and attempts to resolve the issue with assistance from another LPN were unsuccessful due to incompatible connectors. This resulted in a significant delay in the resident's care, and it was determined that the LPN required additional training.
A resident with moderate cognitive impairment and at risk for malnutrition did not receive a physician-ordered dietary supplement for nearly two weeks. The supplement was not available, and although nursing staff contacted the pharmacy, it was not delivered, and follow-up actions were unclear.
A resident with a history of GERD and a choledochoduodenal fistula did not receive tube feeding care as ordered, including receiving water flushes at a higher rate than prescribed and being given an incorrect tube feeding formula without proper authorization. These errors were confirmed by staff interviews and led to the resident experiencing vomiting and increased digestive symptoms.
Staff did not follow Enhanced Barrier Precautions when handling a resident's feeding tube. Despite signage indicating the need for these precautions, an Interim DNS and an LPN were observed wearing only gloves, without gowns, while providing care to a resident with a gastric tube and GERD.
An agency LPN failed to administer prescribed medications and treatments to seven residents with conditions such as GERD, hypothyroidism, Parkinson's Disease, and pain, as documented in the MARs. The DNS confirmed the omissions and attempts to contact the LPN were unsuccessful.
The facility did not maintain an accessible grievance process, as residents and their representatives were unaware of how to file grievances, and forms were not readily available or visible in common areas. Staff interviews confirmed that grievance forms were only provided upon request at nursing stations, and there was no way for residents to submit grievances anonymously. This resulted in very few grievances being filed over a two-year period and left concerns unreported and unresolved.
Four residents, including individuals with dementia, chronic kidney disease, cardiovascular surgery aftercare, and heart failure, did not have their required MDS assessments completed within mandated timeframes. Facility staff, including the DNS and RNCM, confirmed the delays and acknowledged ongoing difficulties in meeting assessment deadlines.
Surveyors found improper food storage, unsanitary kitchen and unit refrigerators, and staff not following beard net requirements. Food items were kept beyond policy limits or left undated and unlabeled, and a dirty fan was used near clean dishware, all contributing to unsanitary conditions.
A resident's right to personal property was not respected when staff confiscated the individual's phone after an accusation of viewing illegal content, following police involvement. The phone was locked away without a formal investigation, despite the resident being cognitively intact and expressing a desire to have the phone returned. Staff provided alternative means of communication, but some were unaware the phone had not been returned, and leadership acknowledged the resident's right to the device.
A resident with a history of stroke was allowed to keep Tylenol and Melatonin at the bedside for self-administration without a documented assessment of their ability to do so safely and without secure storage, contrary to facility policy. Staff interviews confirmed that the required assessment and provision of a lockbox were not completed after a physician's order was obtained.
Multiple deficiencies were observed in the facility's physical environment, including a resident room wall in disrepair, buckled carpet creating tripping hazards in a high-traffic area, and a resident's window that was unsecured and lacked a screen. The Maintenance Director was unaware of some issues and confirmed there was no system in place to routinely check or repair windows for safety.
A resident was coded as having schizophrenia on both admission and quarterly MDS assessments, despite the Director of Nursing Services confirming there was no supporting evidence for this diagnosis in the medical record. This led to an inaccurate assessment of the resident's mental health status.
A resident with dementia and diabetes, who had a history of multiple falls, did not have care plan interventions for fall prevention consistently implemented. Observations showed the room door was not kept open for visibility, and the resident's wheelchair and cane were not placed near the bed as required. Staff confirmed these interventions were not followed, increasing the risk of injury.
An agency LPN was absent from her assigned shift, spending most of the night in her car and failing to administer ordered and PRN medications or treatments to seven residents. Other staff confirmed the LPN's absence and the resulting missed care, with the incident verified through interviews and record reviews.
The facility failed to protect a resident from sexual abuse by another resident with a known history of inappropriate sexual behaviors. Despite staff awareness of the behaviors, the incident was not promptly reported or addressed, leading to the resident feeling uncomfortable and unsafe.
The facility failed to timely report allegations of abuse involving two residents. One resident masturbated in front of another during a movie, and the incident was not reported to the State Agency within the required two-hour timeframe. Multiple staff members were aware but did not take immediate action.
Failure to Arrange Transportation Resulting in Missed Dialysis Treatments
Penalty
Summary
The facility failed to provide transportation for a resident requiring scheduled dialysis treatments, resulting in missed dialysis sessions. The resident was admitted with diagnoses including acute kidney failure, dependence on renal dialysis, and metabolic encephalopathy. The resident’s care plan dated 11/22/25 documented that dialysis was to occur three days a week on Tuesday, Thursday, and Saturday, with transportation to the dialysis center to be provided and the resident to remain free from complications secondary to requiring dialysis. Progress notes showed the resident received dialysis at the hospital on 12/24/25 and did not receive treatment on 12/25/25, and there was no documentation of dialysis treatment on 12/27/25. In interviews, the receptionist stated that she or nursing staff assist with dialysis transportation planning and reported she was unable to set up the resident’s dialysis transportation over the December holiday. A family member reported receiving a call from the dialysis center asking why the resident was not present for dialysis and stated the resident was very sick and had not been admitted in that condition. The family member went to the facility and requested that staff send the resident to the ER for dialysis, which was completed on 12/29/25. An LPN stated that evening shift staff had informed her that the resident’s transportation to dialysis needed to be scheduled and confirmed the resident missed the dialysis treatment that was supposed to occur on 12/27/25. The DNS acknowledged that the resident missed dialysis due to transportation not being scheduled.
Lack of Competency in Tube Feeding Administration Delays Resident Care
Penalty
Summary
Licensed nursing staff failed to demonstrate the necessary competencies to care for a resident with a feeding tube. A resident with a history of Gastroesophageal Reflux Disease (GERD) and choledochoduodenal fistula was admitted with physician orders for scheduled tube feedings. On the scheduled day, an LPN was observed to have difficulty identifying and managing the resident's feeding tube due to a missing connector. The LPN left the room to seek assistance after expressing uncertainty about the correct connection method. The Interim Director of Nursing Services (DNS) also entered the room but was similarly unsure about the appropriate procedure for the feeding tube. Multiple staff members, including the MDS Coordinator, were involved in attempts to resolve the issue, but compatible connectors were not immediately available. As a result, the resident's tube feeding was delayed by two and a half hours. Staff interviews and record reviews revealed that the LPN had not received adequate training in tube feeding administration and required further orientation, as indicated by a skills checklist completed after the incident.
Failure to Administer Prescribed Dietary Supplement as Ordered
Penalty
Summary
A resident admitted with a diagnosis including a gallbladder fistula and identified as being at risk for weight loss and/or malnutrition was not administered a prescribed dietary supplement, Phos-Nak, as ordered by the physician. The care plan required encouraging the resident to eat, consulting with the Registered Dietitian, and following a therapeutic diet, including the administration of Phos-Nak three times daily with meals and at bedtime. Medication administration records showed that the supplement was not given for a period of nearly two weeks, with progress notes indicating the medication was unavailable and on order from the pharmacy. Nursing staff reported contacting the pharmacy to request the supplement, but it was not received, and there was uncertainty regarding follow-up actions by the responsible care manager.
Failure to Follow Tube Feeding Orders and Formula Administration
Penalty
Summary
A deficiency occurred when a resident with a history of GERD and choledochoduodenal fistula, who required tube feeding, did not receive care and services as ordered. The resident's physician orders specified administration of free water via feeding tube at 35 ml/hr for 18 hours per day and enteral feeding with Peptamen AF for the same duration. However, staff administered water flushes at 100 ml/hr instead of the ordered rate, and the resident subsequently experienced a large emesis. The provider was notified, tube feeding was held, and the resident was sent to the emergency department due to ongoing vomiting and concerns about altered electrolytes from the excess water. Additionally, staff ran out of the prescribed Peptamen AF formula and administered Peptamen 1.5 without a physician order or approval from the registered dietician or the initiating team. The resident reported increased digestive symptoms after receiving the incorrect formula. Staff interviews confirmed the errors in both the water flush rate and the tube feeding formula administration.
Failure to Follow Enhanced Barrier Precautions During Feeding Tube Care
Penalty
Summary
Facility staff failed to adhere to Enhanced Barrier Precautions during the care of a resident with a gastric tube. The resident, admitted with diagnoses including GERD and the presence of a gastric tube, required Enhanced Barrier Precautions as indicated by signage outside the room. On two separate occasions, staff members, including the Interim Director of Nursing Services and an LPN, were observed handling the resident's feeding tube and assessing the pump and gastric tube while wearing only gloves and not donning a gown as required. The Interim DNS later acknowledged that neither she nor the LPN wore a gown when accessing the resident's gastric tube.
Failure to Administer Medications and Treatments as Ordered
Penalty
Summary
Staff 17, a former agency LPN, failed to administer prescribed medications and treatments according to physician orders for seven sampled residents. The missed medications included Omeprazole Suspension and water flushes for a resident with esophageal reflux and cerebral palsy, Pantoprazole Sodium for a resident with chronic gastritis and GERD, and Levothyroxine for several residents with hypothyroidism. Additionally, Carbidopa-Levodopa for Parkinson's Disease and Oxycodone for pain were not administered as ordered. These omissions were documented in the Medication Administration Records (MARs) for the affected residents on the specified date. The Director of Nursing Services (DNS) confirmed that Staff 17 did not administer the prescribed medications and treatments during her scheduled shift. The DNS stated that all physician orders are expected to be followed and that medications should be administered as ordered. The facility attempted to contact Staff 17 through the agency staffing company, but was unable to reach her, as two phone numbers were disconnected and the third went to a generic voicemail with no return call received. The residents involved had significant medical histories, including conditions such as esophageal reflux, cerebral palsy, chronic gastritis, hypothyroidism, Parkinson's Disease, and pain management needs. The failure to administer medications and treatments as ordered was confirmed through record review and staff interview, with the DNS acknowledging the lapses in medication administration for all seven residents on the specified date.
Failure to Provide Accessible Grievance Process
Penalty
Summary
The facility failed to ensure a system was in place to receive and resolve resident and/or resident representative grievances, as evidenced by a lack of accessible grievance forms and insufficient communication about the grievance process. Record review showed that only a handful of written grievances were completed by residents or family members over a two-year period, with no grievances filed for most of 2024 and only a few in 2025. During a Resident Council meeting, multiple residents reported they were unaware of the grievance process, did not know how to file a grievance, and felt that reporting concerns to staff was ineffective. Observations throughout the facility revealed no visible information on how to file grievances, submit them anonymously, or access grievance forms. Interviews with staff indicated that grievance forms were not routinely provided to residents and were only available at nursing stations upon request. The Grievance Officer confirmed that forms were not accessible unless given by staff, and the Administrator acknowledged that residents had no means to submit grievances anonymously. This lack of an accessible and transparent grievance process placed residents at risk for unreported and unresolved grievances.
Failure to Complete Timely Comprehensive Resident Assessments
Penalty
Summary
The facility failed to complete comprehensive assessments for four out of eight sampled residents within the required timeframes. Specifically, one resident with dementia had an annual Minimum Data Set (MDS) assessment that was incomplete past the deadline, as confirmed by the Director of Nursing Services (DNS). Another resident, readmitted with chronic kidney disease and a history of transient ischemic attack, did not have an admission MDS completed within the required 14 days. The DNS acknowledged responsibility for this delay. Additionally, a resident admitted after cardiovascular surgery had an admission MDS that was not completed by the deadline, with the responsible Registered Nurse Case Manager (RNCM) confirming the assessment was late and noting ongoing struggles with timely completion. Another resident with acute chronic diastolic heart failure had an admission MDS completed one day late, also acknowledged by the RNCM. These delays in completing required assessments placed residents at risk for unidentified care needs.
Deficient Food Storage, Sanitation, and Staff Hygiene Practices
Penalty
Summary
Surveyors observed multiple failures in food storage and sanitation practices within the facility. In the main kitchen refrigerator, tofu salad and chicken salad were stored for eight days, exceeding the facility's stated four-day discard policy, and two containers of lunch meat were found undated. Staff confirmed the salads were made on the date indicated and should have been discarded earlier. Additionally, staff members were seen in the kitchen without required beard nets, in violation of the facility's Employee Cleanliness Policy, which mandates facial hair be completely covered in food preparation areas. On a unit floor, the refrigerator was found with a spilled substance and crumbs, as well as undated and unlabeled food items, including a foiled item stuck to the bottom and a glass container with food. Staff interviews revealed confusion about responsibility for cleaning and monitoring the refrigerator, with some staff unsure who was accountable for these tasks. Furthermore, a fan covered in dark brown debris was observed blowing onto cleaned utensils and dishware in the dishwashing area, which was acknowledged by the Dietary Manager as inappropriate for the area.
Failure to Respect Resident's Right to Personal Property
Penalty
Summary
Facility staff failed to respect a resident's right to personal property when they confiscated the resident's phone following an accusation of viewing illegal pornography. The incident began when staff observed the resident using their phone and contacted the police, who reportedly instructed staff to take the phone and not return it. The phone was subsequently locked in the Resident Care Manager's office, and the resident, who was documented as cognitively intact, expressed a desire to have the phone returned. Multiple staff interviews confirmed that the phone remained locked away, and there was no formal investigation conducted after the incident. The resident was provided access to a cordless phone for calls and received assistance from staff and a friend to access the internet or obtain a phone without internet capabilities. Some staff were unaware that the resident's phone had not been returned, and facility leadership acknowledged the resident's right to possess their phone.
Failure to Assess and Secure Self-Administered Medications
Penalty
Summary
A resident with a history of stroke resulting in left-sided hemiparesis and hemiplegia was observed to have unsecured medications, including Tylenol and Melatonin, on their bedside nightstand on multiple occasions. The resident had no significant cognitive impairment and had a physician's order allowing these medications to be kept at the bedside for self-administration. However, there was no documented assessment completed to determine the resident's ability to safely self-administer these medications, as required by facility policy. Interviews with staff revealed that the process for assessing the resident's capability to self-administer medications was not followed. The resident was not provided with a lockbox to secure the medications, and staff were unaware that the medications were being kept at the bedside. The lack of assessment and secure storage was confirmed by multiple staff members, including the LPN Care Manager and the Director of Nursing Services, who acknowledged that the required procedures were missed after the physician's order was obtained.
Failure to Maintain Safe and Homelike Physical Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several deficiencies in the physical environment. Observations revealed that the wall to the right of a resident's bed was in disrepair, with scratches and missing paint, and the Maintenance Director was unaware of the issue until it was pointed out. The Administrator confirmed that all resident rooms were expected to be in good condition and properly maintained. Additionally, four sections of carpet, each approximately five feet long, were observed to be buckled up to four inches high in a high-traffic area on the third floor. The Maintenance Director acknowledged that these buckled carpets had been present for a significant amount of time and confirmed they posed tripping hazards, especially for residents with a shuffling gait. A resident admitted after cardiovascular surgery was found to have a bath towel draped over their window to prevent drafts, as the window could be detached and had no screen. The resident demonstrated that the window was not secure and stated it had been this way since admission. After a gust of wind dislodged the window and towel, the Maintenance Director screwed the window shut. The Maintenance Director later acknowledged that the window's arms had broken off and that the detachable window was a safety issue. He also stated there was no system in place to check or audit windows for safety and repair before or during a resident's stay.
Inaccurate MDS Assessment Due to Unsupported Mental Health Diagnosis
Penalty
Summary
The facility failed to complete Minimum Data Set (MDS) assessments that accurately reflected a resident's mental health diagnoses. Specifically, a resident admitted with major depressive disorder and schizophrenia had schizophrenia coded in Section I of both the admission and quarterly MDS assessments. However, upon review, the Director of Nursing Services (DNS) confirmed there was no supporting evidence in the medical record for the diagnosis of schizophrenia, and acknowledged that the MDS should not have been coded with this diagnosis in the absence of documentation. This resulted in an inaccurate assessment for the resident.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
A deficiency was identified when staff failed to implement fall prevention interventions for a resident with dementia and diabetes, who had a history of multiple falls. The resident's care plan included specific interventions such as keeping the room door open for visibility, ensuring the wheelchair was at the bedside, and placing the cane near the bed when the resident was in bed. However, observations revealed that the room door was often closed or only partially open, preventing staff from visualizing the resident. Additionally, the resident's wheelchair was repeatedly found across the room under the television, and the cane was placed next to the bathroom wall instead of near the bed. Staff interviews confirmed that the care plan interventions were not being followed. A CNA and an LPN both acknowledged that the wheelchair and cane should have been near the resident's bed for fall prevention, and the Director of Nursing Services confirmed that the interventions were not in place as directed. These failures to implement the care plan placed the resident at risk for injury due to inadequate supervision and lack of access to necessary mobility aids.
LPN Absence Results in Missed Medications and Treatments
Penalty
Summary
Staff 17, a former agency LPN, failed to adhere to professional standards for medication management and oversight of assigned residents during a night shift. According to interviews and record reviews, Staff 17 was absent from the facility for most of her shift, having slept in her car in the facility parking lot. As a result, seven residents missed their ordered medications and did not receive PRN medications or treatments as required. Staff 17 was found asleep in her car near the end of the shift and indicated she could not finish her duties. Other staff confirmed her absence and the resulting missed medication administration. The Director of Nursing Services (DNS) and other staff verified that Staff 17 was not present to fulfill her responsibilities, which included administering medications and treatments as ordered by providers. Attempts to contact Staff 17 after the incident were unsuccessful, as provided phone numbers were either disconnected or not answered. The investigation confirmed that the lack of licensed nurse oversight during the shift led to unmet medical needs for the affected residents.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to ensure residents were free from sexual abuse, specifically involving Resident 201 and Resident 202. Resident 201, who was moderately cognitively impaired and had a history of socially inappropriate sexual behaviors, masturbated during a movie while sitting next to Resident 202. This incident made Resident 202, who was cognitively intact, feel uncomfortable and unsafe. Despite Resident 201's known history of such behaviors, appropriate measures were not taken to prevent this incident. Staff members were aware of Resident 201's inappropriate behaviors, including masturbating in common areas and exposing private parts, yet failed to adequately monitor or intervene. On the day of the incident, an activity staff member was present but not close enough to prevent or address the behavior. Additionally, there was a delay in reporting the incident, as it was not communicated to the appropriate personnel until two days later. Interviews with staff revealed a lack of immediate action and proper reporting. Staff 7, who was the charge nurse on the day of the incident, did not initiate an investigation or report the incident promptly. Staff 8 and Staff 6 were aware of the incident but did not ensure it was reported to the nurse in a timely manner. This lack of prompt reporting and intervention contributed to the failure to protect Resident 202 from sexual abuse by Resident 201.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to timely report allegations of abuse to the State Survey Agency for two residents. Resident 202, who was cognitively intact, and Resident 201, who was moderately cognitively impaired, were involved in an incident where Resident 201 masturbated in front of Resident 202 during a movie. Resident 202 reported the incident to a CNA the following day, but the CNA did not immediately escalate the report. The incident was eventually reported to the State Agency two days later, which was not within the required two-hour timeframe as per the facility's policy. Staff interviews revealed that multiple staff members were aware of the incident but did not take immediate action to report it. The charge nurse on duty at the time of the incident did not initiate an investigation or report the incident when she first heard about it. It was only after another CNA informed the RNCM two days later that the incident was formally reported to the State Agency. The facility's Administrator confirmed that the report was not submitted timely, as required by their policy.
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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