Myrtle Point Rehabilitation & Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Myrtle Point, Oregon.
- Location
- 637 Ash Street, Myrtle Point, Oregon 97458
- CMS Provider Number
- 385254
- Inspections on file
- 19
- Latest survey
- December 8, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Myrtle Point Rehabilitation & Care during CMS and state inspections, most recent first.
Two residents, both found capable of consenting to sexual activity, were observed engaging in intimate acts in public areas due to the facility's lack of a designated private space for such encounters. Interviews confirmed that while private meetings were requested, only chaperoned interactions were permitted and no private area was provided.
Two residents, one with moderate cognitive impairment and another cognitively intact, were involved in intimate contact observed by staff. Despite the incident, staff did not promptly assess both individuals for their ability to consent or confirm the interaction was consensual, allowing them to remain together without proper evaluation.
A resident with chronic lung disease and moderate cognitive impairment was involved in an incident where another resident was observed with their hands up the first resident's shirt. The event was not reported to administration or the State agency within the required two-hour timeframe, with staff interviews revealing a lack of awareness of the reporting requirement.
The facility failed to employ a director of food and nutrition services with the required certification, risking unmet dietary needs for residents. The Dietary Manager stated she would be certified in February 2025, but no documentation was provided to confirm her current certification. The Administrator was informed of the lack of certification, which was also an issue in previous surveys. The Dietary Manager had not completed training due to her preceptor's passing.
The facility did not submit the required Payroll Based Journal staffing data for a specific quarter in 2024. The administrator was unaware of this omission until the survey team pointed it out, which risked inaccurate staffing data reporting.
The facility failed to ensure that nursing staff demonstrated competency in necessary skills and techniques, as evidenced by the absence of completed competency checklists for three CNAs. This deficiency was identified through interviews and record reviews, indicating inadequate record maintenance to confirm staff competencies, potentially risking poor quality of care for residents.
The facility failed to complete the required annual CNA training and performance reviews for two CNA staff members. The administrator could not provide documentation of the training or reviews, acknowledging that the records did not show the required 12 hours of in-service training. The facility was unable to access previous training records and had not started a new training service.
A facility failed to properly store and discard expired food items in a resident refrigerator, posing a risk of food-borne illness. An observation revealed expired applesauce, a sandwich, pineapple, and carrots, which the Dietary Manager confirmed should have been discarded.
The facility failed to maintain a clean and safe environment for residents, as evidenced by missing hearing aids for a resident with a stroke, a disrepaired window in another resident's room, and dirty sunroom windows obstructing views. Staff were unaware of the hearing aids' location, and maintenance issues were acknowledged but not promptly addressed.
A facility failed to protect residents from verbal abuse and neglect, as evidenced by a former administrator's aggressive behavior towards a resident and inadequate incontinence supplies for others. A resident reported emotional distress from the administrator's verbal abuse, corroborated by staff. Additionally, residents experienced discomfort due to incorrect-sized briefs and insufficient wipes, confirmed by staff and complaints. These deficiencies highlight significant care issues.
The facility failed to provide an ongoing activity program, as a resident expressed a desire to go fishing but was unable due to the facility van being not road legal. The van's registration was out of date, and the title was still in the previous owner's name. Additionally, a period without an Activity Director resulted in a lack of documented activities for several residents, with staff confirming that activities were not occurring despite an activity calendar being posted.
The facility failed to provide adequate staffing, resulting in unmet needs for residents. A resident with dementia was left without a required escort for a medical appointment due to short staffing. Multiple complaints and witness statements confirmed that the facility often operated below state minimum staffing levels, leading to delays in care and services for residents. Staff struggled to provide timely assistance, particularly during evening shifts.
A resident readmitted with MRSA was not placed on infection control precautions, as staff were unaware of the infection. The care plan showed precautions were delayed by 27 days, and a public complaint highlighted the issue alongside the removal of biohazard receptacles.
A resident with diabetes had cavities identified during a dental exam, with recommendations for treatment and a full crown. Despite a follow-up visit where X-rays couldn't be performed due to mental capacity, no referral to another dental provider was made. The facility administrator confirmed the lack of a dental referral setup.
Two residents experienced deficiencies in care at the facility. One resident, with hemiplegia and depression, was moved to a new room without necessary adaptive equipment for over two months. Another resident, with arthritis and intervertebral disc degeneration, used an ill-fitting power wheelchair and had inaccessible personal belongings due to staff inaction. These issues were compounded by a lack of follow-up on a new wheelchair prescription and inadequate unpacking assistance.
A resident, who was cognitively intact and diagnosed with arthritis and intervertebral disc degeneration, alleged emotional and psychological abuse by a former administrator after testing positive for COVID-19. The resident reported feeling bullied and uncomfortable speaking alone with the administrator, who was observed yelling and using an authoritative voice. Despite these allegations, the facility failed to report the incident to the State Survey Agency.
A resident who tested positive for COVID-19 reported feeling bullied and emotionally abused by a former administrator who instructed them to return to their room in an authoritative manner. Despite the resident's claims and corroboration from staff, the facility failed to document or conduct an investigation into the alleged abuse, placing residents at risk.
A resident with arthritis and intervertebral disc degeneration, who was cognitively intact, experienced a delay in receiving assistance with ADLs. The resident activated the call light, but two CNAs left without providing care due to the resident's request to keep quiet and not turn on the light. This resulted in the resident waiting in a soiled brief for 45 minutes to an hour. The facility's protocol for addressing such issues was not followed.
The facility failed to follow physician orders and respond to changes in condition for two residents. One resident did not receive prescribed Miralax for constipation in a timely manner, while another resident with dementia and a UTI showed signs of distress and was not promptly assessed by an LPN. Staff reported the LPN was unresponsive to the resident's needs, leading to potential risks for delayed treatment.
The facility failed to prevent accidents and monitor residents after falls, leading to incidents involving two residents with stroke diagnoses. One resident fell due to malfunctioning entrance doors and a ramp without railings, while another experienced multiple falls due to inadequate supervision and care plan updates. Neurological assessments were not documented after unwitnessed falls, and care plans did not reflect necessary interventions.
A resident with chronic pain did not receive Methadone as ordered due to pharmacy delivery delays and lack of physician notification, leading to unmanaged pain. The resident, who was cognitively intact, reported frequent medication delays, and witnesses confirmed the facility's consistent mismanagement of medications.
A resident with chronic pain experienced multiple missed doses of Methadone due to delays in delivery and waiting on physician orders, despite having a care plan for pain management. The resident, who was cognitively intact, reported frequent issues with late or missed medications, which was corroborated by witnesses. Facility staff acknowledged the resident's frequent absences but did not adequately address the medication management issues.
A resident's food preferences were not honored, leading to unmet needs. The resident reported dissatisfaction with meal schedules and choices, receiving disliked foods, and small portions. The alternative meal menu was removed and not reinstated, contributing to the resident's complaints.
The facility failed to maintain complete and accessible records for two residents, leading to the loss of TB testing records. A former administrator disposed of these records, requiring re-testing. One resident, admitted with blindness and dementia, had no documentation of TB testing prior to June 2024 and refused a test in August 2024. Another resident, with anxiety and dementia, had no prior TB testing documentation but received a test in August 2024. Staff confirmed the loss of records and the need for re-testing.
A resident with spinal stenosis experienced a three-month delay in receiving an MRI due to inaccurate documentation and lack of communication by the facility. The MRI order, issued in June, lacked a physician's signature and clear imaging instructions, leading to the delay until September. Despite multiple calls to update the order, the facility failed to act promptly, as acknowledged by the Social Service Director.
A resident with a history of aggression struck another resident, despite a care plan intervention to keep them at arm's length from others. The facility's investigation ruled out abuse but did not confirm adherence to the care plan, and there was no documentation of the incident in progress notes.
Failure to Provide Private Environment for Consensual Intimacy
Penalty
Summary
The facility failed to provide a private environment for physical intimacy for two residents who were both determined to have the capacity and desire to engage in consensual sexual activity. One resident, admitted with chronic lung disease and moderate cognitive impairment, and another resident, admitted with heart disease and cognitively intact, were observed engaging in intimate acts in public areas both outside and inside the building. Staff documented incidents where the residents were seen with hands inside each other's clothing in non-private settings. Despite both residents being evaluated and found capable of consenting to sexual activity, interviews revealed that the facility did not provide a designated private space for residents to meet for intimacy. One resident reported that while meetings with the other resident were allowed, they were always chaperoned and no private area was made available. Facility staff confirmed that there was no location within the facility designated for private, consensual intimate encounters between residents.
Failure to Assess Resident for Sexual Consent After Intimate Incident
Penalty
Summary
The facility failed to ensure that a resident was properly assessed for sexual consent following an incident involving intimate contact with another resident. One resident, who was moderately cognitively impaired and admitted with chronic lung disease, was involved in an incident where another resident, who was cognitively intact and admitted with heart disease, engaged in heavy petting and placed hands inside the first resident's shirt. Staff observed the incident and separated the residents, but did not immediately assess both individuals for their ability to consent to the interaction or confirm that the interaction was consensual. Staff interviews revealed that after the initial incident, both residents were allowed to remain together in a common area without a timely assessment of their ability to consent. The charge nurse acknowledged that he did not have the opportunity to speak to each resident separately to ensure consent until after a second event occurred. Documentation and staff statements confirmed that the required assessment for sexual consent was not conducted promptly after the incident, which constituted a failure to protect residents from potential abuse or trauma.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to ensure that an allegation of abuse was reported within the required two-hour timeframe for one of four sampled residents. Specifically, a resident with chronic lung disease and moderate cognitive impairment was involved in an incident where another cognitively intact resident was observed with their hands up the first resident's shirt. This incident occurred at 8:30 PM but was not reported to the administrator until 9:30 AM the following day and subsequently to the State agency at 11:08 AM, resulting in a delay of over 12 hours from the time of the incident. Staff interviews revealed that the charge nurse was unaware of the two-hour reporting requirement, while the administrator confirmed that such allegations should be reported within two hours.
Deficiency in Dietary Manager Certification
Penalty
Summary
The facility failed to employ a director of food and nutrition services with the required certification, which placed residents at risk for unmet dietary needs. During an interview, the Dietary Manager, identified as Staff 23, stated she would be certified as a dietary manager in February 2025. However, no documentation was provided to confirm her current certification status. The facility's Administrator, identified as Staff 1, was informed that Staff 23 lacked the required certification and had also not been certified in 2023, as identified during the annual recertification survey that year. Staff 1 mentioned that Staff 23 was working on the classes on Sundays but had not completed the training due to the passing of her preceptor. Staff 1 was unaware that the facility had been previously cited for the same issue in the 2022 and 2023 recertification surveys.
Failure to Submit Payroll Based Journal Staffing Data
Penalty
Summary
The facility failed to submit the required Payroll Based Journal staffing data for the third quarter of fiscal year 2024, covering the period from April 1, 2024, to June 30, 2024. This omission was discovered during a survey when the survey team alerted the facility's administrator to the missing data. The administrator, identified as Staff 1, stated that she was unaware of the failure to submit the data until informed by the survey team. This lack of submission placed residents at risk for inaccurate staffing data reporting.
Lack of Competency Documentation for CNAs
Penalty
Summary
The facility failed to ensure that nursing staff demonstrated competency in the skills and techniques necessary to care for residents, as evidenced by the lack of completed competency checklists for three certified nursing assistants (CNAs). During a review, it was found that the facility did not have the required documentation for Staff 18, Staff 26, and Staff 27, which was requested by the Administrator. This deficiency was identified through interviews and record reviews, indicating that the facility did not maintain adequate records to confirm the competencies of these staff members, potentially placing residents at risk for poor quality of care due to the lack of competent staff.
Failure to Complete Annual CNA Training and Performance Reviews
Penalty
Summary
The facility failed to ensure the required annual Certified Nursing Assistant (CNA) training and annual performance reviews were completed for two of the five sampled CNA staff members. This deficiency was identified during a survey when the administrator was unable to provide documentation of annual performance reviews and in-service training for the identified staff members. The administrator, who was recently hired, acknowledged that the records for the CNA staff did not show the required 12 hours of annual in-service training and did not include annual performance reviews. Additionally, the facility was unable to access previous internet-based training service records and had not yet started using a new internet-based training service.
Improper Food Storage and Expired Items in Resident Refrigerator
Penalty
Summary
The facility failed to ensure proper food storage and timely disposal of expired food items in a resident refrigerator, which was reviewed for food storage and handling. During an observation, it was found that the refrigerator contained several food items with expired dates, including applesauce expired for 7 days, a sandwich expired for 5 days, a dish of pineapple expired for 5 days, and a plastic bag of carrots expired for 4 days. This oversight was confirmed by the Dietary Manager, who acknowledged that the food items should have been discarded by their expiration dates.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to provide a clean and homelike environment and ensure the safety of residents' belongings for two residents and one sunroom. Resident 18, admitted with a stroke, had hearing aids that were not located in her/his room, and staff were unaware of their whereabouts. Despite the issue being reported, no grievance was filed, and the interim Director of Nursing Services (DNS) was unable to provide additional information on the hearing aids' location. Resident 19, admitted with depression and respiratory failure, had a window in her/his room that was in disrepair, with glass improperly reinstalled and caution tape across it. The window was fastened with screws to prevent it from falling out, and maintenance staff acknowledged the need for repair. Additionally, the sunroom, where residents sat in wheelchairs to look outside, had cobwebs on the windows, obstructing the view. Residents expressed dissatisfaction with the dirty windows, and maintenance staff confirmed the need for cleaning. These deficiencies highlight the facility's failure to maintain a clean and safe environment, as evidenced by the missing personal belongings and the unaddressed maintenance issues in the residents' living areas.
Verbal Abuse and Supply Neglect in LTC Facility
Penalty
Summary
The facility failed to protect residents from verbal abuse and neglect, as evidenced by multiple incidents involving staff interactions and inadequate supply provisions. Resident 14, who was cognitively intact, reported being verbally abused by a former administrator, Staff 20, during a COVID-19 isolation incident. Staff and witnesses corroborated that Staff 20 used an authoritative and aggressive tone, causing Resident 14 emotional distress and fear of retaliation, which prevented the resident from filing grievances. Additionally, the facility was found to have neglected the needs of several residents by failing to provide adequate incontinence supplies. Residents 3, 18, and 20, who were dependent on staff for toileting hygiene, experienced issues due to the lack of appropriately sized briefs and insufficient wipes. Complaints were made about the facility's inability to supply the correct size briefs, leading to skin irritation and discomfort for the residents. Staff confirmed that there were delays in supply orders and that donations were relied upon to meet the residents' needs. The facility's failure to provide necessary supplies and protect residents from verbal abuse highlights significant deficiencies in care. The lack of proper incontinence supplies resulted in physical discomfort and potential health risks for the residents, while the verbal abuse incident caused emotional harm. These issues were confirmed by staff interviews and resident statements, indicating systemic problems in the facility's management and care practices.
Deficiency in Resident Activity Program
Penalty
Summary
The facility failed to provide an ongoing activity program to meet the needs of its residents, as evidenced by the case of Resident 6, who expressed a desire to go fishing more often but was unable to do so due to the facility van being not road legal. The van's registration was out of date, and the title was still in the previous owner's name, preventing renewal. This issue was confirmed by multiple staff members, including the Maintenance Director, who acknowledged the problem but could not provide a timeline for resolution. The lack of a functioning van prevented residents from participating in outings, which was a source of dissatisfaction among them, as noted during a resident council meeting. Additionally, the facility experienced a period without an Activity Director, resulting in a lack of documented activities for several residents. A public complaint highlighted that the Social Services and Activity Directors' positions were vacant for a time, leading to no activities being available. Documentation for several residents showed minimal or no participation in activities during this period. Staff confirmed that activities were not occurring despite an activity calendar being posted, and the newly hired Activity Director noted that there were no activities on Sundays when she worked as a CNA before her current role.
Inadequate Staffing Leads to Unmet Resident Needs
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of its residents, as evidenced by multiple instances of insufficient staff coverage. Resident 18, who has dementia and cognitive impairment, was left without a required staff escort for a medical appointment due to short staffing. The facility administrator acknowledged this lapse in care. Additionally, a public complaint highlighted that during certain shifts, the facility operated with only one nurse and one CNA for 27 residents, which did not meet the state minimum staffing requirements. This situation was corroborated by witness statements and a review of staffing reports, which showed numerous days where staffing levels were below the required minimum. Further observations revealed that residents experienced delays in receiving care and services. Resident 14, for example, had to wait several hours for assistance with a simple request for batteries for a television remote. Other residents reported long wait times for call light responses and medication administration. Staff members confirmed that the facility was short-staffed, particularly during the evening shifts, and that they struggled to provide timely care. The facility's administration was aware of these issues, as indicated by statements from the current administrator and interim DNS, who expected staff to address call light activations promptly.
Failure to Implement Infection Control Precautions for MRSA
Penalty
Summary
The facility failed to adhere to infection control standards for a resident who was readmitted with an active Methicillin Resistant Staphylococcus Aureus (MRSA) infection. The resident, initially admitted with a hip fracture, was discharged to the hospital due to pus drainage from the surgical site and later returned to the facility with MRSA. Despite the serious nature of MRSA, there was no documentation in the resident's clinical record indicating that they were placed on any infection control precautions upon readmission. Staff interviews revealed a lack of awareness regarding the resident's MRSA status, and it was confirmed that the resident was not on any infection control precautions. The care plan provided by the facility indicated that precautions were only implemented 27 days after the resident's readmission. This oversight was highlighted by a public complaint received by the State Survey Agency, which also noted the removal of biohazard receptacles and multiple residents with MRSA infections.
Failure to Ensure Follow-Up Dental Appointment
Penalty
Summary
The facility failed to ensure a follow-up dental appointment was made for a resident who was reviewed for dental care. The resident, admitted in April 2023 with a diagnosis of diabetes, underwent an oral exam on March 19, 2024, which revealed cavities and recommended a referral for treatment and a full crown. A subsequent dental visit on May 15, 2024, noted that X-rays could not be performed due to the resident's mental capacity. However, the resident's clinical record did not indicate that a referral to another dental provider was made. On November 8, 2024, the facility administrator confirmed that the resident was not set up for a dental referral related to the treatment recommendations from previous dental appointments.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to accommodate the needs of Resident 8, who was admitted with hemiplegia and depression. Resident 8 was moved to a different room due to a ceiling leak, but the adaptive equipment necessary for bed mobility, such as a trapeze and side rails, was not transferred to the new room. This oversight left Resident 8 without essential adaptive equipment for over two months, as confirmed by both the resident and maintenance staff. Resident 14, admitted with arthritis and intervertebral disc degeneration, experienced issues with mobility and access to personal belongings. Despite being cognitively intact, Resident 14 was using a borrowed power wheelchair that was too large, preventing her/his feet from touching the floor and causing physical discomfort. Although a prescription for a new power wheelchair was requested, there was a lack of follow-up, and the insurance provider initially denied coverage due to incorrect information. Additionally, Resident 14's personal belongings were inaccessible as they were stored in boxes and placed too high in the closet, and staff had not assisted in unpacking them since her/his room change. The facility's failure to address these issues resulted in Resident 14's inability to access her/his belongings and use a properly fitting wheelchair, exacerbating her/his physical pain and anxiety. Staff interviews revealed a lack of awareness and responsibility regarding the unpacking of Resident 14's belongings, highlighting a gap in communication and care coordination within the facility.
Failure to Report Alleged Abuse by Former Administrator
Penalty
Summary
The facility failed to report allegations of abuse involving a resident who was cognitively intact and had been admitted with diagnoses including arthritis and intervertebral disc degeneration. The incident occurred when the resident, who had tested positive for COVID-19, refused to stay in their room. During this time, a former administrator, identified as Staff 20, was reported to have yelled at the resident, which was witnessed by other staff and residents. The resident felt bullied and described the interaction as emotional and psychological abuse, expressing discomfort in speaking with Staff 20 alone. Despite these allegations, there was no indication that the incident was reported to the State Survey Agency. Interviews with various staff members corroborated the resident's account of the events. Staff 25, a CNA, confirmed that Staff 20 yelled at the resident, while Staff 13 observed Staff 20 using an authoritative voice to direct the resident back to their room. Witness 7, a former staff member, noted that the resident did not file grievances due to fear of punishment and observed Staff 20 yelling and cussing in the hallway. Staff 18 also stated that the resident was uncomfortable talking alone with Staff 20. The facility's current administrator and interim DNS acknowledged that they expected such allegations to be reported, yet this was not done.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse involving a resident who was cognitively intact and had tested positive for COVID-19. The incident occurred when the resident was sitting by the elevator, and a staff member, identified as the former administrator, instructed the resident to return to their room in an authoritative manner. The resident expressed feeling bullied and emotionally abused by the staff member's behavior, which included loud talking and refusal to leave the resident alone when requested. Multiple staff members corroborated the resident's discomfort and the staff member's authoritative demeanor. Despite the resident's claims of emotional and psychological abuse, there was no documentation in the resident's clinical records indicating that an investigation was conducted regarding the incident. The facility's administrator and interim DNS acknowledged that an abuse investigation was expected to be completed, yet it was not carried out. This lack of action placed residents at risk for abuse, as the facility did not adhere to its obligation to investigate allegations of abuse thoroughly.
Failure to Assist Resident with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) to a resident who was dependent on staff for care. The resident, who was admitted in May 2023 with conditions including arthritis and intervertebral disc degeneration, was cognitively intact with a BIMS score of 15. The care plan indicated the resident required one-person assistance for most ADLs and was to use a call light for help. On November 6, 2024, the resident reported that after activating the call light, two CNAs responded but left the room without providing assistance, resulting in the resident waiting 45 minutes to an hour in a soiled brief. The CNAs, Staff 13 and Staff 19, left the room because the resident requested they keep quiet and not turn on the light to avoid waking the roommate. The CNAs reported the situation to other staff but did not return immediately to assist the resident. The facility's administrator and interim DNS stated that staff are expected to address such issues by problem-solving with the resident or involving a nurse. However, the CNAs did not follow this protocol, leading to a delay in care. Attempts to contact another staff member, Staff 11, who might have been involved, were unsuccessful.
Failure to Follow Physician Orders and Respond to Resident Needs
Penalty
Summary
The facility failed to respond to changes in condition and follow physician orders for two residents, leading to potential risks for delayed treatment and unmet needs. Resident 4, diagnosed with Parkinson's disease, constipation, and chronic kidney disease, had a physician order for Miralax to be administered if no bowel movement occurred for three days. However, the medication was not given until the sixth day, despite the resident having no bowel movement for five days, which was confirmed by the Director of Nursing Services (DNS). Resident 29, with diagnoses including dementia and a urinary tract infection (UTI), had a preference for limited treatment, including antibiotics. After returning from the hospital with new orders for Levofloxacin, the resident exhibited signs of distress, such as difficulty staying awake and eating, and later had oxygen levels at 64 percent with labored breathing. Despite these critical signs, a former LPN did not assess the resident promptly, even when the resident showed signs of choking and a black tongue. Staff members reported that the LPN was not responsive to the resident's needs, and attempts to contact the LPN for further clarification were unsuccessful.
Failure to Prevent Accidents and Monitor Residents After Falls
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and adequately supervise residents, leading to incidents involving two residents. Resident 6, who was admitted with a stroke and identified as a high fall risk, experienced a fall due to malfunctioning entrance doors. The main entrance door was broken, forcing Resident 6 to use a back door with a ramp lacking railings. This resulted in the resident's electric wheelchair slipping off the ramp, causing a fall and injuries. Despite complaints and observations from staff about the non-functioning doors, there was no documentation or timeline provided regarding when the doors were repaired. Resident 18, also admitted with a stroke, experienced multiple falls due to inadequate supervision and failure to follow care plan interventions. On two occasions, Resident 18 attempted to self-transfer and fell, with the wheelchair brakes not being locked. Despite the unwitnessed falls, neurological assessments were not documented, as confirmed by staff. Additionally, the care plan did not reflect the use of non-slip material on the resident's wheelchair cushion, which was observed during the survey. These deficiencies highlight the facility's failure to ensure proper monitoring and updating of care plans for residents at risk of falls.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to provide pain medications as ordered for a resident with chronic pain, leading to instances of uncontrolled pain. Resident 14, who was admitted in May 2023 with diagnoses including arthritis and intervertebral disc degeneration, had a care plan indicating the need for pain management with Methadone. However, there were multiple occasions documented in February and March 2024 where Methadone was not administered due to delays in delivery from the pharmacy or waiting on a physician order. These missed doses were not communicated to the resident's physician, and there was no documentation explaining the absence of medication on certain dates. The resident, who was cognitively intact with a BIMS score of 15, reported that their pain medications were frequently late or missed almost every month. Witnesses, including complainants, corroborated the resident's claims, stating that the facility consistently mismanaged the resident's medications, causing hardship. Despite the resident's frequent absences from the facility, staff acknowledged the expectation to notify the physician of any missed doses, which was not done in this case.
Failure in Timely Pharmaceutical Services for Pain Management
Penalty
Summary
The facility failed to provide accurate and timely pharmaceutical services for a resident with chronic pain, leading to missed doses of Methadone, a medication prescribed for pain management. The resident, who was admitted in May 2023 with diagnoses including arthritis and intervertebral disc degeneration, had a care plan indicating the need for pain medication as ordered by the physician. However, there were multiple instances in February and March 2024 where Methadone was not administered due to delays in delivery from the pharmacy or waiting on a physician order. These lapses were documented in the Medication Administration Notes, highlighting a pattern of medication mismanagement. The resident, who was cognitively intact with a BIMS score of 15, reported that their pain medications were frequently late or missed, affecting their daily activities and sleep. Witnesses, including complainants, corroborated the resident's claims, stating that the facility consistently mismanaged the resident's medications, causing hardship. The facility staff acknowledged the resident's frequent absences from the facility but did not provide a satisfactory explanation for the missed doses. This deficiency in pharmaceutical services placed the resident at risk for medication errors and inadequate pain management.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of a resident, leading to unmet needs. A complaint was received indicating that a resident was not getting enough food and was not always served the same meals as other residents. The resident expressed dissatisfaction with the meal schedule, as the largest meal was served at lunch instead of dinner, which was contrary to their cultural preference. Additionally, the resident reported not being provided with meal choices and was served foods they disliked, such as beets and Brussels sprouts. When the resident requested a salad, it was reportedly small and lacking in ingredients. The resident also mentioned that the pork chop served was dry. The facility's alternative meal item list was reviewed and found to include options such as cottage cheese and fruit, hotdogs, corndogs, and sandwiches. However, it was noted that the alternative menu was removed during the tenure of a former administrator and had not been reinstated. Staff confirmed that the alternative meal item list was not nutritionally equivalent to the main menu. A CNA reported instances of small meal portions and confirmed that the alternative menu was no longer available, which contributed to the resident going to bed hungry on occasion.
Incomplete and Inaccessible Resident Records
Penalty
Summary
The facility failed to ensure that resident records were complete and accessible, affecting two residents whose records were reviewed. Resident 11, who was admitted in June 2019 with diagnoses including blindness and dementia, was involved in an incident where the State Survey Agency received a complaint about the disposal of medical records, including tuberculosis (TB) testing records, by a former administrator. This led to the need for re-testing, as there was no documentation of TB testing prior to June 2024. It was noted that Resident 11 refused a TB skin test in August 2024. Similarly, Resident 18, admitted in April 2023 with anxiety and dementia, was also affected by the loss of TB testing records. The complaint indicated that the former administrator disposed of these records, necessitating re-testing. There was no documentation of TB testing prior to August 2024, although records show that Resident 18 received a TB skin test in August 2024. Staff confirmed the loss of medical documents and the need to redo TB testing for some residents.
Delay in Radiology Services Due to Documentation Errors
Penalty
Summary
The facility failed to timely obtain radiology services for a resident, which resulted in a delay of approximately three months for a necessary MRI. The resident, who was admitted with a diagnosis of spinal stenosis, had a physician order for an MRI of the left knee issued in June 2024. However, due to inaccurate facility documentation, including the absence of a physician's signature and unclear imaging instructions, the MRI appointment was not scheduled until September 2024. Despite multiple calls from the complainant to update the order and add the physician's signature, the facility's lack of communication contributed to the delay. The Social Service Director acknowledged the delay in addressing the physician's order for radiology services.
Failure to Follow Care Plan Leads to Resident Abuse
Penalty
Summary
The facility failed to follow care plan interventions to protect residents from physical abuse, specifically involving two residents with dementia. Resident 1, who has a history of striking out and aggression, was observed to slap another resident on the hand. Following this incident, Resident 1's care plan was updated to ensure they remained at arm's length from other residents. However, this intervention was not effectively implemented. Subsequently, Resident 1 struck Resident 2 on the face while passing by the nursing station, despite the care plan's directive to keep Resident 1 at a safe distance from others. The facility's investigation ruled out abuse but did not confirm whether the care plan interventions were followed. Additionally, there was no documentation of the incident in the progress notes for either resident. Interviews with the current Administrator and DNS revealed acknowledgment that the care plan was not adhered to, leading to the incident.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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