Nehalem Valley Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wheeler, Oregon.
- Location
- 280 Rowe Street, Wheeler, Oregon 97147
- CMS Provider Number
- 385244
- Inspections on file
- 18
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Nehalem Valley Care Center during CMS and state inspections, most recent first.
A dependent hospice resident with cancer, mixed bladder incontinence, and a coccyx pressure injury was not provided incontinent care or repositioning for about seven hours, despite a care plan requiring checks, changes, and turning at least every two hours. A CNA assigned to the resident acknowledged she only visually checked the brief once, did not change it, and did not reposition the resident due to the resident’s pain, and later wrote a note asking others to keep an LPN from entering the room because care had not been done. Other CNAs and the charge RN reported it was apparent the resident had not been changed, and staff confirmed that standard practice was to provide incontinence care and repositioning per the care plan.
The facility did not provide RN coverage for eight consecutive hours on three reviewed days, as confirmed by staff interviews and daily staffing reports.
The facility did not maintain adequate nursing staff levels, resulting in missed showers, delayed meal service, and prolonged call light response times. Residents reported waiting up to an hour for assistance, and staff confirmed frequent understaffing and difficulty completing basic care tasks in a timely manner.
Staff failed to follow infection control protocols by not donning PPE or performing hand hygiene when entering and exiting rooms of two residents on Contact Precautions, and by not cleaning reusable equipment between uses. Additionally, a CNA was observed wearing the same gloves while assisting multiple residents during meal service, handling food and personal items without changing gloves or performing hand hygiene between tasks.
Two residents were served meals in the dining room using trays covered with black plastic garbage bags, disposable containers, and plastic utensils, while seated with other residents who had standard meal service. Staff initially indicated this was for residents on precautions, but a regional nurse confirmed this was not required by protocol. Both residents expressed a desire to have the same meal service as others.
A resident with dementia was prescribed multiple psychoactive medications, including an antipsychotic, despite showing increasing side effects as measured by AIMS scores. Staff and leadership acknowledged that the antipsychotic was used to address calling out behaviors that were not distressing to the resident, and no comprehensive assessment or gradual dose reduction was performed, with the facility relying on pharmacist reviews instead of their own evaluations.
Staff prepared pureed meals for two residents by adding water to roasted salmon instead of using hot cooking liquid or broth as required by the facility's recipe. The dietary manager confirmed that water should not be used, as it does not provide the necessary nutritional value for residents on pureed diets.
The facility failed to maintain RN coverage for at least eight consecutive hours a day on 41 out of 99 days, risking unmet assessment needs. Additionally, there was no full-time DNS present, leading to confusion and lack of clinical oversight, as confirmed by staff interviews.
Failure to Provide Timely Incontinence Care and Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinent care and repositioning assistance to a dependent resident over a seven-hour period. The resident had diagnoses including cancer and was on hospice, with a care plan indicating mixed bladder incontinence and dependence on staff for toileting. The care plan directed staff to check and change the resident during repositioning, as needed, and throughout the shift, and also documented a pressure injury to the coccyx with instructions for turn/repositioning at least every two hours and more often as needed. On the day in question, a CNA assigned to the resident did not provide incontinent care or repositioning for approximately seven hours of her shift, despite being responsible for these cares. Interviews and the facility’s investigation showed that the CNA acknowledged she had only looked at the resident’s brief early in the shift, thought it appeared dry, and left it unchanged, and that she did not reposition the resident because the resident grimaced in pain when she pulled on the pad. Other CNAs reported that the CNA wrote a note on the CNA message board asking others not to let the nurse enter the resident’s room because the resident had not yet been changed, and that it was obvious to staff later in the shift that the resident had not been changed. The charge nurse became aware near the end of the shift that the resident had not received care, and other CNAs were asked to assist with completing the resident’s cares. Staff interviews confirmed that standard practice was to provide incontinence care and repositioning at least every two hours or according to the care plan, and the administrator acknowledged that the resident was not provided ADL assistance by the CNA for a prolonged period of time.
Failure to Ensure Required RN Coverage
Penalty
Summary
The facility failed to provide registered nurse (RN) coverage for eight consecutive hours per day on three specific days out of forty-three days reviewed. Direct Care Staff Daily Reports showed that there was no RN coverage for the required duration on 2/13/25, 2/15/25, and 6/20/25. This deficiency was confirmed through interviews with the Administrator and Regional Nurse, who acknowledged the lack of RN coverage on the identified days. No additional information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Failure to Provide Sufficient Nursing Staff for Timely Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the care needs of residents in a timely manner across all three resident halls reviewed. Resident Council notes documented missed showers and delays in getting residents to activities and meal service. Review of Direct Care Staff Daily Reports showed that the facility did not meet state minimum CNA staffing requirements on multiple dates. Residents reported significant delays in call light responses, with some waiting up to an hour for assistance, experiencing late showers, and receiving meals late. Some residents had to leave their rooms to seek help due to the lack of available staff. Staff interviews confirmed ongoing staffing shortages, with CNAs frequently assigned to care for 8-12 residents, making it difficult to complete basic care tasks and respond to call lights promptly. Staff described feeling rushed and unable to provide timely showers or assistance, and agency CNAs corroborated that it was common for residents to wait over 20 minutes for call lights to be answered. The facility administrator acknowledged the staffing concerns and the impact on timely resident assistance.
Failure to Implement Proper Infection Control and Hand Hygiene Practices
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices, specifically regarding hand hygiene and the use of personal protective equipment (PPE) for residents on Contact Precautions. Staff were observed entering and exiting rooms of residents on Contact Precautions without donning appropriate PPE or performing hand hygiene, despite clear signage and facility policy. In one instance, a CNA entered a resident's room twice without PPE and did not perform hand hygiene upon exit. In another case, an LPN entered a resident's room without PPE, used a reusable blood pressure device without cleaning it afterward, and placed it on a medication cart without a barrier. Both staff members acknowledged their failure to follow proper procedures, and facility leadership confirmed that staff were confused about the differences between Enhanced Barrier Precautions and Contact Precautions. Additionally, during meal service in the main dining room, a CNA was observed wearing the same gloves while assisting multiple residents, handling food items, touching personal items such as a phone, and performing various tasks without changing gloves or performing hand hygiene between residents. The CNA admitted to only changing gloves and performing hand hygiene twice during meal service and recognized that hand hygiene should have been performed after touching personal items. Facility leadership confirmed that staff were expected to perform hand hygiene between assisting residents in the dining room.
Failure to Provide Dignified Dining Experience for Residents on Precautions
Penalty
Summary
The facility failed to ensure a dignified dining experience for two residents who were observed receiving their meals in the dining room with black plastic garbage bags covering their trays. The meals were served in disposable clamshell containers, with fruit in disposable paper soup cups, and plastic utensils provided, while the residents sat at a communal table with others who did not have similar arrangements. Staff explained that these trays were for individuals on precautions, but the regional nurse later clarified that the use of plastic bags, clamshell containers, and disposable utensils was not part of the protocol for residents on contact precautions. Both affected residents expressed a preference for having a normal tray and being treated like the other residents.
Failure to Assess and Address Unnecessary Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that a resident with dementia was free from unnecessary use of antipsychotic medication. The resident was admitted with diagnoses including a stage four pressure ulcer and dementia, and was prescribed multiple psychoactive medications, including quetiapine, trazodone, venlafaxine, Namenda, and hydroxyzine. Despite the presence of symptoms and side effects associated with psychoactive medication use, as evidenced by increasing Abnormal Involuntary Movement Scale (AIMS) scores, the facility did not adequately assess the continued need for antipsychotic medication. The physician was notified of certain symptoms and reduced the dose of venlafaxine, but did not address the use of quetiapine. The Psychotropic Committee did not order additional gradual dose reductions (GDRs) or assess the appropriateness of continued antipsychotic use despite adverse side effects. Observations and staff interviews indicated that the resident did not exhibit negative behaviors or signs of distress, and staff reported that calling out behaviors had lessened and were not distressing to the resident. However, the facility relied on pharmacist reviews rather than conducting their own assessments for antipsychotic medication use. Facility leadership acknowledged that antipsychotic medication was prescribed to address calling out behaviors that were disturbing to others, but not distressing to the resident, and admitted that a comprehensive risk/benefit assessment should have been completed in light of the adverse side effects.
Improper Preparation of Pureed Foods Using Water Instead of Nutritive Liquids
Penalty
Summary
The facility failed to ensure that pureed foods were prepared using methods that conserved nutritive value and flavor for residents requiring pureed diets. During two observed meals, a cook was seen adding approximately 6-8 ounces of water to roasted salmon while preparing a pureed meal for a resident, instead of using hot cooking liquid or hot broth as specified in the facility's recipe. The cook confirmed the use of water, and the dietary manager later stated that water should not be used for pureed meals, emphasizing that a liquid with more nutritional value was required. This practice resulted in the preparation of pureed food that did not meet the facility's standards for nutritional value and flavor.
Deficiency in RN Coverage and Lack of Full-Time DNS
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least eight consecutive hours a day, as required, for 41 out of 99 days reviewed. This deficiency was confirmed by the facility's administrator, who acknowledged the absence of RN coverage on the specified dates. The lack of consistent RN presence placed residents at risk for unmet assessment needs, as there was no qualified nursing staff available to address potential health concerns during these periods. Additionally, the facility did not have a designated full-time Director of Nursing Services (DNS) for an extended period. Staff interviews revealed that the previous DNS had left in October 2024, and since then, an RN consultant was working remotely as the DNS, but was not physically present in the facility. This absence of a full-time DNS led to confusion among staff, who reported difficulties in identifying leadership and obtaining guidance for clinical questions. The lack of on-site nursing oversight further compromised the facility's ability to manage residents' clinical needs effectively.
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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