Porthaven Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Portland, Oregon.
- Location
- 5330 Ne Prescott Street, Portland, Oregon 97218
- CMS Provider Number
- 385045
- Inspections on file
- 28
- Latest survey
- December 8, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Porthaven Post Acute during CMS and state inspections, most recent first.
A resident with congestive heart failure and delusional disorders was discharged to a home lacking basic utilities and infested with rats, despite prior IDT concerns and without the primary physician's involvement in discharge planning. Documentation did not show that the IDT met to ensure a safe discharge, and facility leadership could not provide further information.
A resident with a known history of violent behavior was not care planned for these risks and subsequently physically assaulted another resident, causing serious injuries including a spinal fracture and prolonged severe pain. The injured resident, previously independent, became bedridden and required increased pain management following the incident. Staff confirmed the event as abuse and noted the significant decline in the resident's condition.
A resident with a history of infective endocarditis had incomplete and missing wound assessments in their medical record, with several assessments lacking key details such as measurements and wound descriptions. Nursing staff also failed to document the resident's refusals of wound care, despite facility policy requiring such documentation. Staff interviews confirmed these documentation lapses.
A resident with a chronic open wound was not placed on enhanced barrier precautions upon admission, and staff did not consistently use required PPE, such as gowns, during wound care. Proper precautions and signage were only implemented after the deficiency was observed, contrary to facility procedures.
A resident with severe cognitive impairment was sexually abused by another resident in a TV area. The facility's records lacked a Sexual Consent Form for both residents involved. Staff intervened immediately, separating the residents and assessing them for injuries. The facility's administrator acknowledged the incident as sexual abuse.
The facility failed to follow infection control standards, including improper disinfection of glucometers and inadequate use of PPE for a resident with open wounds. Staff did not consistently perform hand hygiene, leading to potential exposure to infectious diseases.
The facility failed to maintain a homelike environment, with surveyors identifying cracked light covers, non-functional lights, dirty vent covers, and sharp/jagged edges on walls and corners across multiple halls. These deficiencies were acknowledged by the Administrator and Maintenance Director.
The facility failed to accurately assess two residents for oxygen therapy and wound care. One resident with COPD had inconsistent MDS documentation regarding their need for supplemental oxygen, despite receiving it. Another resident with diabetes had a diabetic foot ulcer misdocumented as a surgical wound in their MDS. These inaccuracies were confirmed by nursing staff.
The facility failed to update care plans for two residents, leading to discrepancies in respiratory care and weight monitoring. One resident received continuous oxygen therapy at a rate not reflected in their care plan, while another had conflicting instructions for weight monitoring. Staff confirmed the care plans did not match current physician orders, placing residents at risk for unmet needs.
The facility failed to involve two residents and their representatives in the care planning process. One resident with dementia had not had a care conference since February, despite the facility's quarterly schedule. Another resident with acute respiratory failure and cognitive decline had no documented care conference since January, with staff unable to confirm a June conference or representative involvement.
A facility failed to notify the State LTC Ombudsman about a resident's hospitalization, as required for advocacy. The resident, admitted with a UTI and bacteremia, was discharged to a hospital, but there was no documentation of Ombudsman notification. The facility administrator confirmed the oversight.
The facility failed to provide two residents with a written notice of the bed hold policy when they were transferred to a hospital due to changes in their medical conditions. This omission was confirmed by the Administrator and Interim DNS, highlighting a lack of documentation in the residents' health records.
A resident with hemiplegia did not receive necessary nail care services as required by physician orders. Despite records indicating nail care was not needed or refused, the resident later stated they would not have refused if offered. Observation confirmed the resident's nails were long and dirty, and staff acknowledged the lack of care.
The facility failed to provide timely antibiotic treatment for a resident with infected wounds due to delayed communication of culture results, and did not notify the physician of significant weight gains. Another resident experienced a medication error when sertraline was not added to the MAR upon readmission, leading to increased behaviors. These deficiencies highlight lapses in following physician orders and timely communication.
The facility failed to implement necessary fall prevention measures and conduct thorough investigations for two residents. One resident, with a history of falls and an amputation, experienced an unwitnessed fall, and the care plan was not followed. Another resident, found on the floor after attempting to go to the bathroom, had an incomplete investigation lacking witness statements. Staff acknowledged the investigations were not thorough, and the care plans were inaccurately documented.
A facility failed to follow physician orders for a resident requiring respiratory care, specifically in the administration of humidity mist via a tracheostomy. The resident had a physician order for humidity mist at a flow rate of eight liters per minute, but it was observed to be set at four liters per minute. This discrepancy was confirmed by the Interim DNS.
A facility failed to employ a PT to provide necessary therapy services to a resident with multiple left toe fractures. Despite hospital orders for PT evaluation and services, the resident did not receive PT from August 6 to August 13 due to the facility's inability to maintain a consistent PT. The Rehabilitation Director confirmed the reduction in therapy services for all residents.
A facility failed to coordinate and document hospice services for a resident with failure to thrive and acute kidney failure. Despite the resident's admission to hospice services, there was no documentation in the health record, and staff were unaware of hospice care details. The Social Services Director and a CNA lacked information on hospice involvement, and an RNCM confirmed the absence of hospice documentation.
A resident's grievance about missing personal property was not addressed by the facility. Despite a complaint being made after the resident's discharge, staff members, including the Social Services Director and LPN Resident Care Manager, were unaware of the issue. The grievance was not recorded in the facility's binder, and the receptionist, who received the complaint, did not report it to management. The administrator and grievance officer were also not informed, highlighting a failure in the grievance reporting process.
The facility failed to provide adequate staffing, resulting in delayed and unmet resident care needs and lengthy call light response times. Observations and interviews revealed multiple instances of call lights not being promptly answered, with wait times ranging from 25 minutes to over an hour and a half. Staff and residents reported consistent short-staffing, leading to missed showers, increased falls, and long wait times for assistance.
Failure to Ensure Safe Discharge Planning
Penalty
Summary
The facility failed to ensure a safe discharge for one resident who was readmitted with congestive heart failure and delusional disorders. The resident was discharged to a family home that lacked running water, electricity, and heat, and was infested with rats. The primary physician reported not being included in discharge planning or informed of the discharge, and the former Social Services Director confirmed discouraging the discharge due to unsafe conditions. Clinical records showed an earlier interdisciplinary team (IDT) meeting determined it was unsafe to discharge the resident, and a social history review documented the resident's preference to return home despite the risks. However, there was no documented evidence that the IDT met to ensure a safe discharge at the time of the resident's release, and facility leadership could not provide additional information regarding the unsafe discharge.
Failure to Protect Resident from Physical Abuse Resulting in Injury and Decline
Penalty
Summary
The facility failed to protect a resident from physical abuse, resulting in significant harm. One resident with a history of violent behavior, as noted in an email from the prior interim DNS, was not care planned for these behaviors, and no interventions were documented to address the risk. This resident physically assaulted another resident in a hallway, pushing the individual to the ground and punching them, which was witnessed by staff and required immediate intervention to separate the two. The assaulted resident, who had a history of multiple spinal fractures and mild cognitive impairment, sustained a lumbar spinal fracture, rib pain, and difficulty breathing as a result of the incident. Following the assault, the resident experienced severe and prolonged pain, as documented in pain records and medication administration records, requiring increased pharmaceutical interventions including acetaminophen, ibuprofen, oxycodone, fentanyl, and morphine. The resident's condition deteriorated, becoming bedridden, refusing care and medications, and exhibiting increased confusion and agitation. Multiple staff interviews confirmed that the resident was previously independent and ambulatory but became bedridden and in significant pain after the incident. Staff also confirmed that the incident was considered assault and abuse. The facility's failure to address the known violent behaviors of the aggressor resident and to implement appropriate care planning and interventions directly led to the physical abuse and subsequent decline of the victim resident.
Incomplete Wound Assessment Documentation and Failure to Record Care Refusals
Penalty
Summary
The facility failed to maintain accurate and complete documentation of wound assessments and care refusals for one resident with a history of acute and subacute infective endocarditis. The resident's medical record showed gaps in weekly wound assessments, with no documentation between certain dates, and several assessments were incomplete, missing critical information such as wound measurements, descriptions, and wound type. Additionally, refusals of wound care by the resident were not documented in the medical record as required by facility policy. Interviews with nursing staff confirmed that wound assessments were not fully completed and that refusals of care were not consistently documented. Staff acknowledged that the assessment forms were not always filled out after wound care was provided, and that documentation of interventions and resident responses to refusals was lacking. These actions and omissions resulted in incomplete and inaccurate medical records for the resident.
Failure to Implement Enhanced Barrier Precautions for Chronic Wound
Penalty
Summary
The facility failed to follow infection control standards for a resident with a chronic open wound to the left foot. Upon admission, there was no documentation in the clinical record indicating that enhanced barrier precautions were implemented for the resident, despite facility procedures requiring such precautions for conditions like chronic wounds. During an observed dressing change, staff placed an enhanced barrier precaution sign on the resident's door and donned appropriate PPE, but it was confirmed that prior to this, staff had not consistently worn the required PPE, such as gowns, when providing care. The resident reported that this was the first time staff had worn PPE gowns during wound care since admission. Staff interviews confirmed that enhanced barrier precautions should have been in place from admission, including signage and PPE use, but these measures were not implemented until the day of observation.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse by another resident. The incident involved two residents, one with Alzheimer's disease and the other with a genetic disorder causing developmental and intellectual disability. The resident with Alzheimer's was cognitively intact according to their MDS, while the other resident had severe cognitive impairment. The facility's records showed no evidence of a Sexual Consent Form being completed for either resident. An incident occurred where one resident was observed rubbing the genitalia of the other resident in a TV area, which was immediately reported and the residents were separated. The facility's staff, including an LPN and an RN, assessed both residents for injuries, and none were noted. The incident was reported, and both residents were placed under monitoring, with one resident receiving 1:1 supervision. The facility's administrator acknowledged the occurrence of sexual abuse. The facility's policies on abuse and sexual consent were not effectively implemented, as evidenced by the lack of a Sexual Consent Form and the occurrence of the incident.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to infection control standards, particularly in the use of glucometers and the management of residents with wounds. Staff 32, an agency RN, was observed using a glucometer on two residents with diabetes without properly disinfecting it according to the manufacturer's instructions. Instead of using the recommended CaviWipe towelettes, Staff 32 used alcohol prep pads, which are not effective against bloodborne pathogens. This practice was confirmed by the facility's Infection Preventionist, who was unsure of the effectiveness of alcohol wipes against such pathogens. Additionally, the facility did not follow its own Transmission Based Precautions Policy for a resident with open and draining wounds. Staff 24 was observed transporting the resident without wearing the required personal protective equipment (PPE) such as gloves and a gown. The resident's wounds were uncovered, and a trail of fluid was left on the floor, which was not promptly cleaned, leading to multiple staff and residents stepping in it. Staff 15 and other CNAs acknowledged the lack of proper PPE use and the failure to manage the resident's leaking wounds effectively. The facility also failed to enforce its Hand Hygiene Policy. Staff members were observed not performing hand hygiene after touching their masks, between assisting residents, or after handling dirty food trays. Staff 26 and Staff 27 admitted to not consistently performing hand hygiene, and Staff 13 stated she was not taught to clean her hands between picking up dirty trays. The facility's administration confirmed that staff were expected to perform hand hygiene when entering and exiting resident rooms and after touching potentially contaminated surfaces.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment for residents, as observed during a survey conducted from August 12 to August 16, 2024. The survey identified several environmental deficiencies across three of the four halls reviewed. These included a cracked light cover with missing chunks near a room on the annex hall, non-functional lights in the annex hall and dining room, and dirty vent covers in multiple rooms and hallways. Additionally, there were several instances of torn or jagged baseboards and broken plastic wall protectors with sharp edges in various locations, including near the O2 storage closet, emergency exit, and the entrance to the clean laundry area. The surveyors noted that these environmental issues posed a risk of residents living in an unkempt environment. The presence of sharp and jagged edges on walls and corners, as well as non-functional lighting, could potentially compromise the safety and comfort of the residents. On August 16, 2024, the facility's Administrator and Maintenance Director acknowledged these concerns during the survey, indicating awareness of the deficiencies identified.
Inaccurate Assessments for Oxygen Therapy and Wound Care
Penalty
Summary
The facility failed to accurately assess two residents for oxygen therapy and wound care, leading to deficiencies in their care. Resident 22, who was admitted with diagnoses including a heart attack and chronic obstructive pulmonary disease, had physician orders for supplemental oxygen therapy at varying levels over several months. However, the resident's Minimum Data Set (MDS) assessments from June to August did not reflect the need for supplemental oxygen, despite multiple observations confirming the resident was receiving it. This discrepancy was acknowledged by a registered nurse case manager, indicating an oversight in accurately documenting the resident's oxygen therapy needs. Resident 37, readmitted with conditions such as diabetes and peripheral vascular disease, had a diabetic foot ulcer noted in podiatry outpatient notes. However, the resident's July MDS inaccurately documented the presence of a surgical wound instead of a diabetic foot ulcer. This inaccuracy was confirmed by the Director of Nursing Services and the Interim Director, highlighting a failure in the assessment process for the resident's wound care needs.
Inaccurate Care Plans for Respiratory Care and Weight Monitoring
Penalty
Summary
The facility failed to ensure that care plans were accurately revised to reflect the current needs of residents, specifically for two residents reviewed for respiratory care and unnecessary medications. Resident 22, who was admitted with diagnoses including a heart attack and chronic obstructive pulmonary disease, had a discrepancy between the physician's order and the care plan regarding supplemental oxygen therapy. The physician's order from July 2024 indicated that the resident should receive oxygen therapy at 2 to 4 LPM continuously, while the care plan from May 2024 stated oxygen should be administered at 2 LPM as needed. Observations in August 2024 showed the resident receiving oxygen at 3 LPM continuously, and staff confirmed the care plan did not match the current orders. Similarly, Resident 28, admitted with heart failure, had conflicting instructions regarding weight monitoring. The care plan from May 2024 indicated weekly weighing, whereas the physician's orders from August 2024 required daily weighing. A CNA expressed uncertainty about the correct frequency, relying on the care plan for guidance. The Interim DNS confirmed the need for the care plan to be updated to reflect the physician's orders. These discrepancies placed residents at risk for unmet needs due to inaccurate care plans.
Failure to Involve Residents in Care Planning
Penalty
Summary
The facility failed to involve residents and their representatives in the care planning process, as evidenced by the cases of two residents. Resident 4, who was admitted in May 2009 with a diagnosis of dementia, had not had a care conference since February 2024, despite the facility's policy of conducting these conferences quarterly. Staff confirmed that Resident 4 was overdue for a care conference, indicating a lapse in the facility's adherence to its care planning schedule. Similarly, Resident 41, admitted in January 2023 with acute respiratory failure and moderate cognitive decline, had not had a documented care conference since January 2024. Although staff mentioned a care conference supposedly took place in June 2024, they were unable to provide documentation or confirm the involvement of the resident's representative. This lack of documentation and involvement highlights a failure in the facility's process for ensuring regular and inclusive care planning for its residents.
Failure to Notify Ombudsman of Resident Hospitalization
Penalty
Summary
The facility failed to notify the Office of the State Long Term Care Ombudsman about the hospitalization of a resident, which is a requirement for ensuring advocacy. This deficiency was identified during an interview and record review, where it was found that there was no documentation indicating that the Ombudsman was informed about the discharge of a resident to an acute care hospital. The resident in question was admitted to the facility in May 2024 with diagnoses including a urinary tract infection and bacteremia. The resident's discharge to the hospital was recorded in the Discharge MDS on May 23, 2024. However, the facility administrator confirmed that the Ombudsman was not notified of the resident's discharge.
Failure to Provide Bed Hold Policy Notice During Hospital Transfers
Penalty
Summary
The facility failed to provide residents with a written notice of the bed hold policy at the time of transfer to a hospital, as required. This deficiency was identified for two residents who were reviewed for hospitalization. Resident 4, admitted in May 2009 with diagnoses including epilepsy and dementia, experienced a change in condition on January 31, 2024, necessitating a transfer to a hospital. Upon review of Resident 4's health record, there was no documentation indicating that a copy of the facility's bed hold policy was provided at the time of transfer. This was confirmed by both the Administrator and the Interim Director of Nursing Services (DNS) on August 15 and 16, 2024, respectively. Similarly, Resident 56, admitted in May 2024 with diagnoses including a urinary tract infection and bacteremia, was transferred to a hospital on May 23, 2024, due to a change in condition. A review of Resident 56's health record also revealed a lack of documentation showing that the bed hold policy was provided at the time of transfer. This omission was confirmed by the same staff members on the same dates. The failure to provide this critical information placed residents at risk of not understanding their choices and potential financial responsibilities during hospital transfers.
Failure to Provide Nail Care Services
Penalty
Summary
The facility failed to provide nail care services to a resident who required assistance with activities of daily living (ADL) due to a stroke resulting in hemiplegia. The resident was admitted in February 2020 and had physician orders from July 2022 for a licensed nurse to check and trim fingernails and toenails weekly. However, from June to August 2024, the Licensed Nurse (LN) Care Records indicated that nail care was marked as not needed on several occasions, and the resident reportedly refused nail trimming on two dates in June 2024. On August 13, 2024, the resident expressed that their nails were too long, nail care had not been offered recently, and they would not have refused if it had been offered. Observation confirmed the resident's nails were extended and dirty, and a staff member acknowledged that the nails had not been trimmed for an extended period.
Delayed Antibiotic Treatment and Medication Error
Penalty
Summary
The facility failed to initiate timely antibiotic treatment and follow physician orders for two residents, leading to unmet needs. Resident 28, admitted with heart failure, diabetes, and a foot ulcer, had a wound culture taken on 6/27/24, which showed infection. However, the results were not communicated to the provider until 7/18/24, delaying the start of antibiotics until that date. Additionally, the facility did not notify the physician of Resident 28's significant weight gains as required by the physician's orders, which occurred on multiple occasions in July and August 2024. Resident 4, admitted with depression, had a medication error when sertraline, prescribed upon hospital readmission on 4/10/23, was not added to the MAR. This oversight led to increased physical and verbal behaviors, as noted in a psychiatric consultant's progress note. The medication was only restarted on 5/6/24, over a year after the initial order. Staff confirmed the medication error, acknowledging the failure to transcribe the order upon readmission.
Inadequate Fall Prevention and Investigation
Penalty
Summary
The facility failed to implement necessary interventions to reduce the risk of falls and did not conduct thorough investigations following falls for two residents. Resident 37, who was admitted with conditions including diabetes and an amputation, was identified as high risk for falls. Despite this, the resident experienced an unwitnessed fall in their room. The care plan, which included measures such as keeping personal items within reach and wearing nonskid footwear, was not followed, and the investigation lacked detailed information about the circumstances of the fall. Staff acknowledged that the investigation was not thorough and that the care plan was inaccurately documented. Similarly, Resident 360, admitted with a urinary tract infection and acute kidney failure, was found on the floor after attempting to go to the bathroom. The investigation into this incident was incomplete, lacking witness statements, as the only witness, a CNA, was not interviewed. Staff acknowledged that the investigation did not provide a complete picture, and the possibility of abuse or neglect could not be ruled out due to the lack of thoroughness in the investigation.
Failure to Follow Physician Orders for Respiratory Care
Penalty
Summary
The facility failed to adhere to physician orders for a resident requiring respiratory care, specifically in the administration of humidity mist via a tracheostomy. The resident, admitted in March 2024 with diagnoses including respiratory failure and malnutrition, had a physician order dated March 13, 2024, specifying the use of humidity mist at a flow rate of eight liters per minute at all times. However, on August 15, 2024, it was observed by a Licensed Practical Nurse (LPN) that the humidity mist was set at four liters per minute, contrary to the physician's order. This discrepancy was confirmed later the same day by the Interim Director of Nursing Services (DNS), who acknowledged that the humidity mist should have been set at eight liters per minute at all times.
Failure to Provide Physical Therapy Services
Penalty
Summary
The facility failed to employ a Physical Therapist to provide necessary therapy services to a resident who was reviewed for therapy services. This deficiency was identified through interviews and record reviews. The resident, who was admitted with multiple left toe fractures, had hospital orders from August 6, 2024, for a physical therapy (PT) evaluation and services. However, from August 6, 2024, to August 13, 2024, the resident had not been evaluated by a PT and consequently did not receive PT services to assist with transfer safety and mobility. On August 14, 2024, the Rehabilitation Director acknowledged the facility's inability to maintain a consistent physical therapist, which led to a reduction in the frequency and duration of therapy services for all residents, including the resident in question.
Lack of Coordination and Documentation of Hospice Services
Penalty
Summary
The facility failed to coordinate and document hospice services for a resident who was admitted with diagnoses including failure to thrive and acute kidney failure. The resident was admitted to hospice services shortly after admission to the facility, but there was no documentation in the resident's health record regarding hospice care, including contact information, physician's orders, hospice care plan, or hospice notes. Interviews with staff revealed a lack of awareness and communication regarding the hospice services being provided to the resident. The Social Services Director was unaware of when hospice care began, and a CNA had not seen any hospice providers or communicated with hospice staff. An RNCM acknowledged the absence of hospice documentation in the resident's health record.
Failure to Address Grievance on Missing Personal Property
Penalty
Summary
The facility failed to follow up on a grievance related to missing personal property for a resident who was admitted in June 2020 with a diagnosis of depression. A public complaint was received in July 2024 regarding the missing items after the resident was discharged in April 2024. The complainant, identified as Witness 1, reported the missing belongings to the facility via phone but did not receive a response. Staff members, including the Social Services Director and the LPN Resident Care Manager, stated they had not received any complaints or grievances from the resident or their representatives about the missing items. The facility's grievance binder showed no record of a grievance from the resident or their representatives. The receptionist acknowledged receiving a call from the complainant about the missing items but could not recall if it was reported to management. The administrator and the grievance officer both stated they had not been informed of the issue. The grievance officer emphasized that all grievances, whether written or verbal, should be reported to her or the administrator, and the administrator confirmed that verbal grievances should be treated with the same importance as written ones.
Inadequate Staffing and Delayed Call Light Response
Penalty
Summary
The facility failed to have adequate staff available to meet resident care needs in a timely manner, resulting in delayed and unmet needs and lengthy call light response times. Observations from 5/9/24 through 5/13/24 revealed multiple instances where call lights were not responded to promptly, with wait times ranging from 25 minutes to over an hour and a half. For example, on 5/9/24, a call light in one room was activated at 11:33 AM and was not responded to until 1:15 PM, resulting in a wait time of one hour and 42 minutes. During this period, the resident's spouse repeatedly sought assistance, and staff were observed walking past the room without responding to the call light. Interviews with staff and residents further highlighted the issue of inadequate staffing. Staff members reported being consistently short-staffed, with high-acuity residents requiring extensive care. One CNA mentioned being assigned several high-acuity residents, making it difficult to provide timely care. Another CNA stated that the facility had been short-staffed since 9/2023, leading to missed showers and increased resident falls. Residents also expressed concerns about long wait times for assistance, particularly around mealtimes when CNAs were occupied with feeding residents who required total assistance. The staffing coordinator admitted to determining CNA staffing based on mandatory minimum ratios without considering resident acuity needs. This lack of communication regarding resident acuity contributed to the ongoing problem of long call light response times. The facility administrator acknowledged the issue but stated that staffing was typically based on mandatory minimum ratios, with an expectation that call lights be responded to within 15 minutes.
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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