Pilot Butte Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bend, Oregon.
- Location
- 1876 Ne Highway 20, Bend, Oregon 97701
- CMS Provider Number
- 385138
- Inspections on file
- 20
- Latest survey
- September 25, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Pilot Butte Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and high elopement risk left the facility unsupervised, walking 1.8 miles before being found by police. The facility failed to follow the care plan, which included 15-minute checks and supervision, leading to the resident's elopement.
A resident with ALS reported discomfort due to cold temperatures in her/his room and hall, which were set at 68 degrees. Despite complaints to management and nursing staff, no action was taken. CNAs confirmed the cold conditions and resident complaints. The Maintenance Director tested temperatures but did not document results, while the DNS acknowledged the thermostat should be set between 71 and 81 degrees for comfort.
The facility failed to provide therapeutic diets to three residents, including those with diabetes and malnutrition. A resident with end-stage kidney disease did not receive a diabetic diet as prescribed, while another resident with malnutrition did not receive nutritionally enhanced meals. Additionally, a diabetic resident on a low carbohydrate diet received extra carbohydrates and did not receive the fruit they ordered. The Dietary Manager acknowledged the lack of adherence to prescribed dietary requirements.
The facility failed to provide meals that were palatable, attractive, and at an appetizing temperature, affecting three residents. A resident with cancer reported cold and chewy food, while another with malnutrition received a meal with raw hamburger. A third resident with a surgical infection experienced cold food upon delivery. Test trays confirmed these issues, and staff acknowledged the deficiencies.
The facility failed to ensure beard restraints were worn during meal preparation, as observed in a kitchen review for sanitary food practices. Despite a policy requiring beards to be covered, the Dietary Manager and a Cook were seen preparing food without beard restraints. The Dietary Manager was unaware of this requirement, and the RD later confirmed the necessity of beard coverings.
A facility failed to obtain informed consent for a resident's medication, buspirone, which was incorrectly listed as an antidepressant instead of an anxiolytic. The resident, with dementia and agitation, had a physician's order for buspirone, but the consent form did not accurately reflect the medication's classification. The DNS confirmed the error, acknowledging the lack of informed consent.
A resident with a history of stroke and anxiety, who was cognitively intact, consistently refused showers because they were scheduled at night, contrary to their preference. Despite requests for a different bathing schedule, no changes were made, and an investigation into the refusals was not initiated. Staff acknowledged the resident should have been informed about alternative shower schedules.
The facility failed to provide advance directive information to three residents, despite care conference forms indicating the presence of such directives. One resident with impaired cognition and two cognitively intact residents reported not receiving any information about advance directives. The Social Service Director confirmed the absence of documentation in their clinical records.
A facility failed to issue an Advanced Beneficiary Notice (ABN) to a resident who transitioned from a Medicare skilled stay to Medicaid coverage. The resident, admitted with respiratory failure, had a Medicare stay that ended, after which they continued under Medicaid. A review revealed no ABN was provided, a lapse acknowledged by a Regional Nurse Consultant.
Three residents reported abuse by a former agency CNA, Staff 23, who provided rough and inappropriate care. Despite being cognitively intact, the residents experienced verbal and physical abuse, which was confirmed by the facility's investigation.
The facility failed to update care plans for two residents, one with discontinued anticoagulant therapy and another started on Ativan. The care plans lacked necessary revisions to reflect medication changes and specific interventions, as confirmed by the Resident Care Manager.
The facility failed to follow physician orders and care plans for two residents, leading to unmet care needs. One resident missed eight doses of prescribed medication for restless leg syndrome, while another resident's care plan to avoid contact with a specific individual was not enforced, resulting in an uncomfortable encounter in the dining room. The issues were acknowledged by the facility's administration.
A resident with a history of stroke and cognitive intactness requested a hearing doctor appointment, which was not scheduled by the facility. Despite being hard of hearing and recommended for hearing aids months prior, the resident did not receive the necessary audiology exam. The Social Service Director and RN Resident Care Manager acknowledged the oversight, and the resident's son was contacted to arrange the appointment.
The facility failed to accurately assess and follow physician orders for pressure ulcer care for two residents. One resident's heels were not floated as ordered, and another resident's sacral wound was inaccurately assessed and documented, leading to a Stage 4 pressure ulcer. Staff interviews revealed communication and documentation lapses.
A resident with moderate cognitive impairment and a history of stroke was identified as a moderate risk for elopement, yet the facility failed to implement an elopement care plan. Observations showed the resident moving freely throughout the facility, and staff confirmed the oversight.
A facility failed to monitor a dialysis access site and provide appropriate dietary accommodations for a resident with end-stage kidney disease. Despite a care plan requiring daily assessment of the dialysis shunt and specific dietary needs, records showed no post-dialysis monitoring, and the resident reported not receiving meals during dialysis. Staff acknowledged the oversight, but the Dietary Manager was unaware of the required meal accommodations.
A facility failed to assist a resident with discharge planning, leading to confusion and anxiety. The resident, with moderate cognitive issues, wanted to return home, but the facility did not specify what was needed for a safe discharge. The family requested a home evaluation and was informed of the need for 24/7 support, but the facility did not provide details on care or equipment. The resident expressed confusion, and the family and local unit reported a lack of communication and assistance from the facility.
A facility failed to provide non-pharmacological interventions before administering PRN Ativan to a resident with dementia, risking sedation. The resident's care plan noted a risk for Ativan side effects, yet the medication was given 53 times in May 2024, often with oxycodone, without clear documentation of anxiety symptoms or interventions. Staff interviews revealed inconsistent documentation and intervention practices.
A resident with high blood pressure and end-stage kidney disease did not receive their prescribed hypertensive medication, metoprolol succinate, after returning from the hospital. The medication was last given before the resident's hospital discharge, and upon return, the orders were not double-checked, leading to a lapse in administration.
Two residents with diabetes did not receive meals according to their preferences and dietary needs. One resident frequently received incorrect meals, while another received carbohydrates despite being on a controlled carbohydrate diet. The Dietary Manager admitted there was no documentation on portion sizes or dietary restrictions, leading to unmet needs.
A resident with chronic respiratory failure was not offered the Prevnar 20 vaccine, despite being eligible. This oversight was confirmed by the DNS during an interview.
A facility failed to report an unwitnessed fall with serious bodily injury to the State Agency. A resident with a history of falls and dementia was found with injuries including a fractured elbow requiring surgery. Despite the severity, no Facility Reported Incident was submitted.
The facility failed to thoroughly investigate an unwitnessed fall with a major injury involving a resident with a history of falls. Critical details were missing from the investigation, such as witness statements, reasons for the resident's actions, and whether care interventions were followed. The incident was also not reported to the state agency as required.
The facility failed to ensure a safe environment for a resident with a neck fracture and history of falls. The resident was found on the bathroom floor with a detached toilet, which had been left unsecured by the Maintenance Director without proper signage or staff notification.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure the safety of a resident with severe cognitive impairment, leading to an elopement incident. The resident, admitted for a five-day respite stay, had diagnoses including Alzheimer's Disease, dementia, anxiety disorder, and restlessness. The resident was identified as a high risk for elopement due to dementia and exit-seeking behavior. Despite this, the facility did not follow the care plan, which included 15-minute checks and encouraging the resident to remain in supervised areas. The resident was found by law enforcement in a roundabout, approximately 1.8 miles from the facility, after walking alongside and crossing a busy highway. The resident's care plan included interventions to monitor every 15 minutes and redirect when wandering, but these were not followed. Visual checks were supposed to be conducted every 30 minutes but stopped nearly four hours before the elopement occurred. Staff interviews revealed that not all staff were aware of the care plan's safety checks, and some staff did not attempt to redirect the resident's exit-seeking behavior. The resident was last seen by staff at 6:30 PM, and the elopement was discovered when the police returned the resident to the facility at 7:45 PM. The facility's investigation noted that the resident was ambulatory, could almost run, and was a high risk for elopement and falls. Despite setting off two alarms and needing frequent visual checks, the resident was able to leave the facility by following another visitor out the door. Staff acknowledged the lack of individualized interventions in the care plan and the failure to follow the care plan, which contributed to the resident's elopement.
Removal Plan
- Current residents identified as elopement risks would have their care plans reviewed to reflect person centered care.
- All current residents would be reassessed for risk of elopement. Any identified residents' plan of care would be updated to include individualized, personalized interventions.
- The elopement book would be updated to include any newly identified residents.
- All facility staff would be educated on the residents identified at risk for elopement and their individualized care plan interventions as well as procedures to initiate if a resident eloped. Staff who were on leave or under COVID restrictions would be required to complete the education prior to returning work.
- Daily audits would be completed by the Interdisciplinary Team (IDT) to ensure residents were properly identified for elopement risk, elopement care plans were individualized, and staff followed care plan elopement interventions. Any identified issues would be immediately corrected.
- Daily audits would continue, then weekly for three months. Results of the audits would be presented to the QAPI team.
Failure to Maintain Comfortable Temperature Levels
Penalty
Summary
The facility failed to maintain comfortable temperature levels in Pine Meadow Hall, affecting the residents' comfort. Resident 26, who has ALS, reported that her/his room and the hall were too cold, causing discomfort. Despite reporting the issue to management and nursing staff, no action was taken to resolve the temperature problem. Observations confirmed that the room and hall were cold, with the thermostat set to 68 degrees. Staff 15 and Staff 16, both CNAs, acknowledged the cold conditions and resident complaints. Staff 14, the Maintenance Director, admitted to testing room temperatures without documenting results or conducting audits, and was aware of Resident 26's complaints. Staff 2, the DNS, verified the thermostat setting and acknowledged awareness of the resident's complaints, noting that the thermostat should be set between 71 and 81 degrees for comfort.
Failure to Provide Therapeutic Diets
Penalty
Summary
The facility failed to provide therapeutic diets to three residents, which placed them at risk for unmet nutritional needs. Resident 2, who was admitted with end-stage kidney disease and diabetes, had discharge orders for a diabetic diet. However, the Dietary Manager admitted that there were no prescribed recipes or portion control guidelines for preparing meals for residents requiring a diabetic diet. The Registered Dietitian acknowledged that therapeutic diets, including diabetic diets, should be printed and followed, but this was not done. Resident 23, admitted with a diagnosis of malnutrition, was supposed to receive nutritionally enhanced meals. However, the resident reported not receiving the ordered oatmeal for breakfast and was observed with a meal that did not include any beverages. The Dietary Manager confirmed that if a resident did not complete a meal order, the facility prepared whatever was on the menu, which sometimes did not include the resident's preferences. Similarly, Resident 28, who was on a low carbohydrate diet due to diabetes, reported receiving extra carbohydrates despite marking them out on the meal order and not receiving the fruit they ordered. The Dietary Manager acknowledged these issues, indicating a failure to adhere to prescribed dietary requirements.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to ensure that meals were palatable, attractive, and served at an appetizing temperature, affecting the quality of food provided to residents. This deficiency was observed in the kitchen and among three residents. Resident 9, who was admitted in 2023 with a diagnosis of cancer and was cognitively intact, reported that the food was always cold and the meat was chewy. A test tray delivered to surveyors confirmed that the plate warmer was cool to touch, the meat was hard, and the rice was lukewarm. Staff members, including the Director of Nursing Services (DNS) and a Regional Registered Nurse (RN), acknowledged these issues. Resident 23, admitted in 2024 with a diagnosis of malnutrition and also cognitively intact, experienced a similar issue with food quality. During lunch, Resident 23 received a taco casserole with raw hamburger, which was verified by the Dietary Manager. A test tray delivered to surveyors confirmed the same issues with food temperature and texture. Additionally, Resident 11, admitted in 2023 with a surgical infection and moderate cognitive impairment, reported that the food was cold by the time it arrived in their room. The test tray confirmed that the food was not hot, and the DNS acknowledged this problem.
Failure to Use Beard Restraints During Meal Preparation
Penalty
Summary
The facility failed to ensure that beard restraints were worn during meal preparation, which was observed in one of the sampled kitchens for sanitary food practices. This deficiency was identified through observation, interview, and record review. The facility's policy, dated January 2024, required that beards be clean, well-groomed, and completely covered with a beard covering. However, on May 28, 2024, at 8:10 AM, the Dietary Manager and a Cook were observed preparing food in the kitchen without beard restraints. The Dietary Manager indicated a lack of awareness regarding the requirement for staff to wear beard coverings. On May 29, 2024, at 12:01 PM, the Registered Dietitian acknowledged that staff were indeed required to wear beard restraints while working in the kitchen.
Failure to Obtain Informed Consent for Medication Administration
Penalty
Summary
The facility failed to obtain informed consent for the administration of medication to a resident, which was identified during an interview and record review. The resident, who was admitted in December 2019 with diagnoses including dementia, restlessness, and agitation, had a physician's order dated April 11, 2024, for buspirone, a medication used to treat anxiety. However, the consent form signed on the same date incorrectly listed buspirone as an antidepressant, detailing the risks and benefits of an antidepressant medication instead. On May 30, 2024, the Director of Nursing Services (DNS) confirmed that buspirone is an anxiolytic medication and acknowledged that the resident and their representative were not provided with informed consent for the correct medication classification.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to evaluate and accommodate a resident's preference for bathing times, leading to a deficiency in honoring resident choices. Resident 18, who was admitted in 2023 with diagnoses including stroke and anxiety, was cognitively intact and required partial to moderate assistance for bathing. The resident's care plan indicated that bathing should be provided according to their preferences twice a week. However, the resident consistently refused showers on multiple occasions in May 2024 because they were offered at night when the resident preferred to be in bed. Despite the resident's request for a different bathing schedule, no changes were made, and an investigation into the refusals was not initiated as expected. Staff acknowledged that the resident should have been informed about alternative shower schedules.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to ensure that advance directive information was provided to residents, affecting three out of four sampled residents. Resident 11, admitted with a surgical infection, was noted to have impaired cognition. Despite a care conference form indicating the presence of an advance directive, the Director of Nursing Services (DNS) confirmed that Resident 11 did not have an advance directive in their clinical record, nor was there documentation showing that advance directive information was provided. Family members of Resident 11 also stated they were not informed about advance directives. Resident 34, who was cognitively intact and admitted with a skin infection, stated they did not have or want an advance directive and confirmed that the facility did not provide any related information. Similarly, Resident 40, admitted with a UTI and also cognitively intact, reported not having an advance directive and not receiving any information from the facility. The Social Service Director acknowledged the absence of advance directives in the clinical records of Residents 34 and 40 and failed to provide documentation that advance directive information was given.
Failure to Provide Advanced Beneficiary Notice
Penalty
Summary
The facility failed to provide an Advanced Beneficiary Notice (ABN) to a resident who transitioned from a Medicare skilled stay to Medicaid coverage. The resident, who was admitted to the facility in August 2016 with a diagnosis of respiratory failure, had a skilled Medicare stay from January 10, 2023, through January 19, 2023. After this period, the resident continued to reside in the facility under Medicaid coverage. However, a review of the resident's medical record showed no evidence that an ABN was issued following the change in payor status from Medicare to Medicaid. This oversight was acknowledged by a Regional Nurse Consultant on May 31, 2024, indicating a lapse in the facility's process for notifying residents of their financial responsibilities when coverage changes occur.
Failure to Prevent Abuse by Agency CNA
Penalty
Summary
The facility failed to prevent abuse for three residents, identified as Residents 14, 21, and 31, who were all cognitively intact and had various medical conditions. Resident 14, who was admitted with a diagnosis including stroke, reported that a former agency CNA, Staff 23, provided rough personal care and attempted inappropriate actions during bowel care. Despite Resident 14's protests, Staff 23 continued the rough treatment. The facility's investigation confirmed that abuse occurred between Staff 23 and Resident 14. Resident 21, admitted with spinal stenosis, reported verbal and physical roughness from Staff 23. Despite asking for gentler care, Resident 21 experienced verbal abuse and rough handling. The facility's investigation concluded that Staff 23 was abusive toward Resident 21. Similarly, Resident 31, who had hemiplegia, reported emotional and physical abuse by Staff 23, including being called a liar and being handled roughly during care. The investigation confirmed that Staff 23 was abusive toward Resident 31 as well.
Failure to Revise Care Plans for Residents on Medications
Penalty
Summary
The facility failed to revise care plans for two residents, leading to a deficiency in care. Resident 2, admitted with end-stage kidney disease and stroke, was hospitalized due to a hematoma while on an oral anticoagulant. Upon discharge, the anticoagulant was discontinued, but the care plan was not updated to reflect this change, as acknowledged by the Resident Care Manager. Resident 34, diagnosed with dementia, was started on Ativan in March 2024. However, the care plan did not include specific interventions or causes for anxiety related to Ativan use. The Resident Care Manager confirmed that the care plan was not updated to include resident-specific behaviors or interventions after Ativan was initiated.
Failure to Follow Physician Orders and Care Plans
Penalty
Summary
The facility failed to adhere to physician orders for two residents, leading to unmet care needs. Resident 9, who was admitted in 2017 with diagnoses including end-of-life care and restless leg syndrome, was prescribed Benztropine to be taken every evening at bedtime. However, a review of the resident's clinical record for May 2023 revealed that Resident 9 missed eight doses of this medication. This lapse was confirmed by the Director of Nursing Services (DNS) on May 29, 2023, after Resident 9 reported going without the necessary medication for eight days. Resident 7, admitted in February 2024 with a diagnosis of depression, expressed feeling unsafe around another resident, identified as Resident 33. A care plan was established to prevent contact between Resident 7 and Resident 33, in accordance with Resident 7's preferences. Despite this, on May 30, 2023, Resident 33 was observed sitting next to Resident 7 in the dining room without staff intervention. The Social Service Director was informed and subsequently had Resident 33 moved. The Administrator and DNS later confirmed that the care plan was not updated after Resident 33 moved out of the shared room, acknowledging the need for ongoing staff training.
Failure to Schedule Audiology Exam for Resident
Penalty
Summary
The facility failed to schedule an audiology exam for a resident who was reviewed for communication needs. The resident, who was admitted in April 2023 with a diagnosis of stroke, was cognitively intact and had requested to see a hearing doctor as noted in a provider progress note dated January 24, 2024. Despite this request, the resident, who was hard of hearing and had been recommended hearing aids approximately eight months prior, did not have a hearing appointment scheduled. On May 28, 2024, the resident expressed difficulty hearing, and on May 29, 2024, the Social Service Director acknowledged the lack of a scheduled hearing appointment. A progress note from the same day indicated that the resident's son was contacted to confirm or schedule a hearing exam. On May 31, 2024, the RN Resident Care Manager confirmed awareness of the resident's hearing difficulties and acknowledged that the resident had not seen a hearing doctor.
Failure to Accurately Assess and Follow Orders for Pressure Ulcer Care
Penalty
Summary
The facility failed to accurately assess and follow physician orders for pressure ulcer care for two residents. Resident 4, who was admitted with diagnoses including stroke and aphasia, had a physician order to float their heels while in bed, apply skin prep to their heels each shift, and ensure a foam boot was applied to their right heel at all times. However, observations on 5/29/24 revealed that Resident 4's heels were resting on the bed and their feet were exposed to the air, contrary to the physician's orders. Staff interviews indicated a lack of communication and documentation regarding the resident's refusal to float their heels, and changes to treatment were not updated in the resident's clinical record. Resident 19, admitted with bladder cancer, had an open area on the sacrum that was initially documented as a small sacral pressure wound. However, subsequent evaluations revealed it was a Stage 4 pressure ulcer, indicating a deep tissue injury from the beginning. The facility failed to conduct weekly Skin and Wound Evaluations between 1/26/24 and 3/1/24, and the wound was inaccurately assessed and documented in the Treatment Administration Record (TAR) and physician orders. Staff acknowledged the inaccuracies in the wound assessment and documentation.
Failure to Provide Elopement Care Plan for At-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision for a resident who was at risk for elopement. The resident, admitted in April 2024 with a diagnosis of stroke, was identified as having moderate cognitive impairment and a moderate risk for elopement as per an evaluation conducted in May 2024. Despite this, a review of the resident's care plan on May 29, 2024, showed no evidence of an elopement care plan. Observations from May 28 to May 31, 2024, noted the resident ambulating with a walker throughout various areas of the facility, including hallways, the dining room, the front lobby, and occasionally other resident rooms. On May 30, 2024, the facility's administrator and DNS confirmed the resident's risk for elopement but acknowledged the absence of a corresponding care plan.
Failure to Monitor Dialysis Access and Provide Appropriate Diet
Penalty
Summary
The facility failed to implement orders and consistently monitor a dialysis access site for a resident with end-stage kidney disease and stroke, who was admitted in 2024. The resident required dialysis and had specific dietary needs to avoid high phosphorus and potassium foods. Despite a care plan revision on 5/24/24 to assess the dialysis shunt for bruit and thrill daily and provide diet according to orders, the May 2024 Treatment Administration Record (TAR) showed no post-dialysis monitoring of the site. The resident reported leaving for dialysis before breakfast and not receiving food until returning late for lunch. Staff acknowledged the need for daily monitoring of the dialysis site and the provision of meals during dialysis, but the Dietary Manager was unaware of the special meal accommodations required, and the diet restrictions were not revised to address the resident's needs.
Failure in Discharge Planning for Resident
Penalty
Summary
The facility failed to assist a resident with discharge planning arrangements, which led to confusion and anxiety for the resident. The resident, who was admitted with a surgical infection and had moderate cognitive issues, expressed a desire to return home. The family requested to be notified before discharge to prepare for the resident's care, but the facility did not specify what needed to be set up at the resident's home. During a care conference, the family requested a home evaluation and was informed that the resident required 24/7 support. However, the facility did not provide details on who would provide care or what equipment was needed for a safe discharge. The resident expressed confusion about the discharge process, stating that communication from the facility was lacking. The Therapy Director noted that the resident had exhausted therapy benefits and was not eligible for additional therapy, and there was uncertainty about who would provide care for the resident at home. The Social Service Director was unsure about the resident's living arrangements and did not provide the family with information on resources. The family and local unit reported that the facility did not communicate effectively or assist with the necessary arrangements for the resident's discharge, including a home evaluation and caregiver training.
Failure to Provide Non-Pharmacological Interventions Before PRN Antianxiety Medication
Penalty
Summary
The facility failed to ensure non-pharmacological interventions were provided prior to the administration of PRN antianxiety medication for a resident diagnosed with dementia. The resident's care plan, updated in March 2024, indicated a risk for side effects from Ativan, an antianxiety medication. In May 2024, the Medication Administration Record (MAR) showed that the resident was administered Ativan 53 times, with only one instance documented as ineffective. Progress notes from the same month revealed that Ativan was often given simultaneously with oxycodone, making it unclear if pain reduction could have alleviated the resident's anxiety. The notes lacked descriptions of the resident's anxiety manifestations or specific interventions attempted before medication administration. Interviews with staff members highlighted a lack of documentation and intervention prior to administering PRN antianxiety medication. A CNA noted that the resident experienced anxiety due to delusions and a desire to be with family, and that calling the family sometimes helped. An LPN stated that staff were required to document the behavior and interventions on the MAR or in progress notes, but this was not consistently done. The Resident Care Manager confirmed that staff should identify the cause of anxiety and provide specific interventions before administering medication. However, no documentation was provided to show that such interventions were attempted for the resident in question.
Failure to Administer Hypertensive Medication
Penalty
Summary
The facility failed to ensure the proper administration of a hypertensive medication, metoprolol succinate, for a resident with high blood pressure and end-stage kidney disease. The resident was admitted to the facility in 2024 and had a care plan revised on May 13, 2024, which included monitoring vital signs and administering medications as per physician orders. After being discharged from the hospital on May 24, 2024, with instructions to continue metoprolol succinate, the medication was last administered on May 21, 2024, and not resumed upon the resident's return. On May 31, 2024, the Resident Care Manager acknowledged that the orders were not double-checked as expected, resulting in the medication not being administered as ordered.
Failure to Honor Resident Food Preferences and Dietary Needs
Penalty
Summary
The facility failed to honor the food preferences of two residents, both of whom were cognitively intact and had specific dietary needs due to their diabetes diagnosis. Resident 22, admitted in April 2023, reported not receiving requested meal items on multiple occasions. For instance, the resident requested milk for cereal but was informed it was unavailable, and on another occasion, requested scrambled eggs but received a different meal. Similarly, Resident 28, who was on a controlled carbohydrate diet, reported receiving meals with carbohydrates despite marking them out on the meal order. The Dietary Manager, Staff 4, acknowledged the lack of written documentation regarding portion sizes and dietary restrictions for residents on specialized diets such as CCHO, NEM, or NAS. This lack of documentation contributed to the facility's inability to meet the specific dietary needs and preferences of the residents, as evidenced by the repeated instances of incorrect meal deliveries. The absence of clear dietary guidelines and documentation led to the unmet needs of the residents, as observed and reported during the survey.
Failure to Provide Required Immunizations
Penalty
Summary
The facility failed to provide necessary immunizations to a resident who was eligible for the Prevnar 20 vaccine. The resident, admitted in August 2023, had a diagnosis of chronic respiratory failure. Upon review, it was found that the resident was not offered the Prevnar 20 vaccine, despite being eligible. This oversight was acknowledged by the Director of Nursing Services during an interview.
Failure to Report Serious Fall Incident
Penalty
Summary
The facility failed to report an unwitnessed fall with serious bodily injury to the State Agency for a resident admitted in August 2023 with diagnoses including hip fracture, history of falls, and dementia with cognitive decline. On August 31, 2023, the resident was found in bed with a skin tear above the left eye and another on the right elbow, along with bruising and excess fluid in the elbow. The resident was sent to the hospital, where it was determined that the fall resulted in a fractured elbow requiring surgery and a laceration above the eye. Despite these injuries, the facility did not submit a Facility Reported Incident to the State Survey Agency. This was confirmed by the Administrator on April 16, 2024.
Failure to Investigate Unwitnessed Fall with Major Injury
Penalty
Summary
The facility failed to thoroughly investigate an unwitnessed fall with a major injury involving a resident who had a history of falls and was at risk for additional falls. The incident report indicated that the resident was found in bed with a skin tear above the left eye and another on the right elbow, and the resident was sent to the hospital with a fractured elbow requiring surgery. However, the investigation did not address critical details such as how the resident got back into bed, whether the roommate was a witness, or if the CNA was interviewed. Additionally, there was no information on why the resident was trying to go to the bathroom alone despite being care planned for assistance, and no documentation on whether care planned interventions were implemented or if abuse and neglect were ruled out. The unwitnessed fall with a major injury was also not reported to the state agency as required. The administrator confirmed that the investigation document provided for the resident's fall was incomplete and lacked thoroughness. The investigation failed to include statements from potential witnesses, details on the resident's condition, and an assessment of whether the care interventions were followed. This lack of a comprehensive investigation placed the resident at risk for additional falls and potential abuse, as the facility did not adequately address the circumstances surrounding the fall or ensure that proper protocols were followed.
Failure to Prevent Accident Hazards
Penalty
Summary
The facility failed to ensure the environment was free of potential accident hazards for a resident admitted with a neck fracture and a history of falls. On the evening of 8/15/22, a CNA found the resident on the floor in their bathroom, with the toilet detached from the floor and on its side. The Maintenance Director had been notified earlier that the toilet was loose due to stripped floor mounting screws and had placed the toilet against the wall for repairs the next morning. However, the Maintenance Director did not ensure that Out of Order signs were posted, the door was locked, or evening staff were notified, leading to the resident's fall.
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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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