Portland Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Portland, Oregon.
- Location
- 12441 Se Stark Street, Portland, Oregon 97233
- CMS Provider Number
- 385228
- Inspections on file
- 24
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Portland Health & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with chronic respiratory failure and CHF, who required one-to-one supervision during meals for aspiration precautions, was found alone with a partially eaten meal and no staff present. The speech therapist confirmed the lack of supervision, and the assigned CNA was unaware of the resident's care plan interventions.
The facility failed to timely assess and address changes in condition for two residents with skin conditions. One resident experienced significant pain and untreated fractures due to delayed response to reports of pain and injury. Another resident had untreated self-inflicted scratches and scabs, which were not reported to the physician or treated as required. The facility did not monitor or document the condition of the wounds, leading to inadequate care.
The facility failed to adequately assess and revise care plans for fall prevention, resulting in multiple incidents involving three residents. One resident, admitted with a history of falls, experienced several falls and was hospitalized, ultimately passing away. Another resident with frequent falls and impaired cognition had multiple non-injury falls, with care plan interventions not consistently followed. A third resident fell out of bed, and temporary safety measures were not implemented while awaiting a perimeter mattress. The facility's failure to implement timely and effective fall prevention measures placed residents at risk for injury.
The facility failed to facilitate Resident Council meetings, as required by their policy, since March 2024. Despite the Activities Director's claim that residents were uninterested, the Resident Council president and other residents expressed a desire for meetings. The Administrator, who started in August 2024, confirmed the absence of meetings, relying on information from the previous DNS without further verification.
The facility failed to provide a qualified Activities Director, impacting residents' needs. The Activities Director, hired with minimal experience, received no training in developing or implementing programs for adults in a nursing facility. She relied on internet resources and lacked guidance on working with residents with dementia or communication difficulties. The Administrator and DNS confirmed the lack of training and were assisting her with activity ideas.
The facility did not complete annual performance reviews for five CNAs, hired between 2017 and 2023, as required. This lapse was confirmed by the Business Office Manager and the Administrator, placing residents at risk of care from potentially incompetent staff.
A facility failed to prevent cross contamination by storing clean laundry items on the soiled side of the laundry room. Staff responsible for housekeeping and laundry confirmed the improper storage, and the Business Office Manager overseeing these departments acknowledged the error. The facility administrator also recognized that clean linens should not have been stored on the dirty side.
The facility failed to ensure accurate assessments for three residents, leading to unmet care needs. A resident with chronic respiratory failure had unaddressed hearing impairments, another was inaccurately assessed as having teeth despite being edentulous, and a third resident was incorrectly coded as needing more assistance with eating than required. Staff confirmed these inaccuracies, and the MDS Coordinator acknowledged errors in the assessments.
A facility failed to conduct a PASARR Level II evaluation for a resident with serious mental illness indicators. Despite a positive Level I PASARR and ongoing behavioral issues, no Level II evaluation was completed. The Social Services Director lacked training on the PASARR process, and the facility administrator admitted the evaluation should have been conducted.
Two residents in a LTC facility were not provided with person-centered activities as required by their care plans. One resident, with cognitive impairments, was not engaged in exercise classes or one-to-one sessions, while another resident, enrolled in hospice care, did not receive personalized activities like listening to music or going outside. The activities director lacked training, and the facility acknowledged the need for improvement.
A resident with a history of pain and contracted fingers on the left hand did not receive timely pain management before wound care treatments, despite physician orders for PRN oxycodone. The resident and a family member reported that pain medication was often administered too late to be effective. Staff interviews revealed inconsistencies in pain management practices, with an LPN failing to offer medication before treatment, contrary to the DNS's expectations.
A resident with bipolar disorder, depression, and panic disorder did not receive necessary behavioral health care services. Despite increased depression and aggression, the facility failed to revise care plan interventions or refer the resident to an in-house psychiatrist. The resident remained isolated and expressed suicidal ideations, with staff acknowledging the inadequacy of interventions and monitoring.
A resident in hospice care experienced delayed pain management due to ineffective communication between the facility and hospice provider. A fentanyl patch order was delayed by several days, and the patch was placed incorrectly on the resident's arm instead of the chest. Family and hospice staff reported ongoing communication issues, and facility staff were unaware of specific care instructions.
A resident, admitted for aftercare following surgical amputation and assessed as cognitively intact, overheard a former hospitality aide using a homophobic slur during a dinner service. The resident felt afraid and uncomfortable, fearing retaliation due to past experiences. Multiple staff members confirmed the incident, although the aide did not recall using the slur. The facility's investigation noted the resident was placed on alert monitoring for psychosocial well-being.
The facility failed to maintain a safe and comfortable environment, as a resident's bed mattress was found to be severely worn, making it difficult for the resident to move. Additionally, offensive odors, particularly of urine, were reported and observed in various areas, including bathrooms and hallways, with cracked tiles and inadequate sealing contributing to the issue. Staff confirmed the need for mattress replacement and repairs to address the odor problem.
A facility failed to ensure the correct POLST was available for a resident with chronic obstructive pulmonary disease, leading to a discrepancy in the resident's code status. The resident had two conflicting POLST documents, one indicating full code and the other DNR. Despite the resident's indication of wanting to be full code, staff confirmed the code status was inaccurately documented as DNR.
Failure to Provide Required Supervision for Aspiration Precautions
Penalty
Summary
The facility failed to implement care plan interventions for aspiration precautions for a resident with chronic respiratory failure and congestive heart failure. The resident's care plan required one-to-one supervision during all meals due to aspiration risk. On one occasion, the resident was found alone in their room with a partially eaten meal tray and no staff present, despite calling out for assistance. The speech therapist later confirmed the resident should have been under one-to-one supervision while eating and observed the meal tray unattended. The assigned CNA was unaware of the resident's need for supervised eating and stated it was their first shift working with the resident. The RCM also confirmed the resident's requirement for aspiration precautions and one-to-one supervision during meals.
Failure to Timely Address Changes in Condition and Skin Issues
Penalty
Summary
The facility failed to timely assess and address changes in condition for two residents with skin conditions, leading to significant pain and untreated injuries. Resident 8, who had a history of hemiplegia and hemiparesis following a stroke, experienced increased pain in the right knee and ankle, which was not promptly addressed. Despite multiple reports of pain and a confirmed diagnosis of fractures in the distal fibula and medial malleolus, there was a delay in providing adequate pain relief and in arranging for hospital evaluation. The resident reported significant pain and confirmed the injury occurred during a transfer, yet the facility did not act swiftly to address the resident's condition. Additionally, Resident 8's care plan required staff to monitor for changes in skin integrity, but a blackened toe was not reported in a timely manner. A CNA observed a red blister on the resident's toe but failed to report it immediately, leading to a delay in assessment and treatment. The facility's investigation acknowledged the failure to identify and address the skin issue promptly. Resident 22, admitted with a history of stroke, had multiple self-inflicted scratches and scabs on the upper extremities that were not evaluated or treated as per physician's orders. Despite observations by staff and complaints from the resident, the wounds were not reported to the physician or NP, and no treatment was implemented. The facility failed to monitor and document the condition of the wounds, resulting in a lack of appropriate care and intervention.
Inadequate Fall Prevention and Care Plan Revisions
Penalty
Summary
The facility failed to adequately assess and revise care plans for fall prevention, resulting in multiple incidents involving three residents. Resident 108, admitted with a history of falls and requiring supervision, experienced several falls within the facility. Despite being identified as high risk for falls, the care plan was not effectively revised following each incident. The investigations into these falls were delayed and incomplete, failing to identify and mitigate potential hazards. This lack of timely intervention and supervision led to Resident 108's hospitalization and subsequent death. Resident 40, with a history of frequent falls and impaired cognition, experienced multiple non-injury falls over several months. Although identified as high risk, the facility did not consistently implement or revise fall prevention strategies. Observations revealed that care plan interventions, such as keeping the wheelchair out of sight and engaging the resident in activities, were not consistently followed. Staff acknowledged the need for more thorough root cause analysis and intervention to prevent further falls. Resident 48, admitted with a traumatic subdural hemorrhage, fell out of bed, prompting the need for a perimeter mattress. However, temporary safety measures were not care planned or implemented while awaiting the mattress. Staff were unaware of the resident's fall risk status and recent incidents, indicating a lack of communication and adherence to care plans. The facility's failure to implement timely and effective fall prevention measures placed residents at risk for injury.
Failure to Facilitate Resident Council Meetings
Penalty
Summary
The facility failed to ensure that residents were provided with the opportunity to organize and participate in the Resident Council, as required by their policy. The policy, dated May 2002, stated that the Resident Council was intended to promote resident interest and involvement in the facility and serve as a forum for residents to voice concerns and suggest changes. The council was supposed to meet monthly or at a frequency determined by the council members. However, a review of the facility's Resident Council Minutes revealed that the last meeting occurred in March 2024, despite the facility having a census of 55 residents as of October 2024. Interviews with staff and residents indicated a lack of initiative to continue the Resident Council meetings. The Activities Director, hired in May 2024, stated that meetings did not occur because residents were not interested. However, the Resident Council president and other residents expressed a desire to have meetings, but none had been organized since the previous Activities Director left. The facility's Administrator, who started in August 2024, confirmed the absence of meetings and mentioned that he was informed by the previous Director of Nursing Services that residents were not interested, which he accepted without further verification.
Unqualified Activities Director Leads to Deficiency
Penalty
Summary
The facility failed to provide a qualified professional to direct the activities program, which affected the residents' physical, mental, and psychosocial needs. The facility's Key Personnel list identified Staff 14 as the Activities Director, who was hired in May 2024. Staff 14 admitted to having minimal experience and no training in developing or implementing an activities program for adults in a nursing facility. She relied on internet resources to develop the program and did not receive training on working with residents with dementia or communication difficulties. The previous administrator was supposed to enroll her in an activity training course, but this did not occur. The facility's Administrator and DNS confirmed that Staff 14 did not receive the necessary training and were assisting her with activity ideas until she could be trained.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to conduct annual performance reviews for five Certified Nursing Assistants (CNAs), which is a requirement to ensure competent staffing. Personnel records revealed that CNAs hired on various dates, ranging from 2017 to 2023, did not receive their mandatory annual performance evaluations. This oversight was confirmed by the Business Office Manager and the Administrator, who acknowledged that the expected annual reviews were not completed for these staff members. The lack of performance evaluations placed residents at risk of receiving care from potentially incompetent staff.
Improper Laundry Storage Leading to Cross Contamination Risk
Penalty
Summary
The facility failed to properly store laundry to prevent cross contamination, as observed during a tour of the laundry room. A metal rack containing clean towels, fabric room divider curtains, and sheets was found on the soiled side of the laundry room, covered partially by a cloth sheet held with metal binder clips, leaving the top uncovered. Staff 26, responsible for housekeeping and laundry, confirmed that these items were new and clean but acknowledged that they were improperly stored on the soiled side. This improper storage was confirmed by Staff 11, the Business Office Manager overseeing housekeeping and laundry, who recognized that clean items should not be stored on the soiled side. The facility administrator also acknowledged the error, stating that the clean linens should not have been stored on the dirty side.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure accurate assessments for three residents, leading to unmet care needs. Resident 14, admitted with chronic respiratory failure, was found to have impaired hearing that was not accurately captured in the MDS assessment. Despite being cognitively intact, Resident 14 struggled to hear staff and other residents, and there were no interventions in place to address this issue. Staff members confirmed the resident's hearing difficulties, and the MDS Coordinator acknowledged the oversight in the assessment. Resident 45, admitted with gram-negative sepsis, was inaccurately assessed as having teeth, despite being edentulous. The resident reported not being assessed for swallowing and expressed dissatisfaction with the soft food provided, as they were accustomed to eating regular food at home. Staff confirmed the resident's edentulous status, and the MDS Coordinator admitted to a coding error. Additionally, Resident 22, who had a stroke, was inaccurately coded as requiring supervision or touch assistance with eating, whereas they only needed set-up assistance. Staff confirmed the resident's ability to eat independently after receiving set-up help, highlighting the inaccuracies in the MDS assessment.
Failure to Complete PASARR Level II Evaluation
Penalty
Summary
The facility failed to complete a PASARR Level II evaluation for a resident who had a positive Level I PASARR indicating serious mental illness. The resident, admitted in November 2022, had diagnoses including bipolar disorder, depression, and panic disorder. The initial PASARR Level I conducted on November 9, 2022, identified indicators of serious mental illness, but no Level II evaluation was completed. The resident's condition included increased depression and behaviors such as verbal and physical aggression, swearing, and resisting care, as noted in subsequent evaluations and care plans. Despite these indicators, a second PASARR Level I conducted on March 15, 2023, after a hospitalization, did not identify serious mental illness, and its accuracy was not verified. The resident's family member reported requesting a mental health evaluation multiple times without success. The Social Services Director admitted to lacking formal training on the PASARR process and was unaware of any actions taken following the initial Level I screen. The facility administrator acknowledged that a Level II evaluation should have been conducted following the initial screen.
Failure to Provide Person-Centered Activities
Penalty
Summary
The facility failed to provide an ongoing person-centered activity program for two residents, leading to a deficiency in meeting their psychosocial needs. Resident 40, who was readmitted with diagnoses including diabetes and metabolic encephalopathy, had a care plan that emphasized the need for activities such as exercise classes and one-to-one sessions. Despite these requirements, observations and staff interviews revealed that Resident 40 was not engaged in group or one-to-one activities, and the activities director admitted to a lack of training and experience in developing suitable programs for the resident. Similarly, Resident 48, who was admitted with a traumatic subdural hemorrhage and was enrolled in hospice care, expressed preferences for activities like watching television, listening to music, and going outside. However, the resident's activity logs showed no participation in group activities or one-to-one visits. Staff interviews indicated a lack of awareness of the resident's interests, and the activities director confirmed that no personalized activities were offered to Resident 48. The deficiency was further highlighted by the activities director's acknowledgment of not having developed enhanced activity programs for the residents and the administrator's admission of the need for improvement in this area. The lack of personalized activities for both residents placed them at risk of a decline in psychosocial well-being and diminished quality of life.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide appropriate and timely pain management for a resident with a history of right upper quadrant pain, low back pain, and arthritis. The resident was observed to have contracted fingers on the left hand, which were painful to move. Despite physician orders directing the administration of PRN oxycodone 30 minutes to an hour before wound care treatment, the resident reported that pain medication was often given just prior to or even after the treatment, which did not allow sufficient time for the medication to take effect. This was corroborated by a family member who expressed concerns about the timing of pain medication administration. Staff interviews revealed inconsistencies in pain management practices. A CNA acknowledged the resident's complaints of pain and took care when assisting with personal care. However, an LPN stated that she did not offer pain medication prior to treatment because the resident did not complain about pain. During an observation, the resident expressed distress and demanded pain medication before treatment. The DNS stated that nurses were expected to assess the resident's pain level and offer medication before treatments, indicating a failure to adhere to these expectations.
Failure to Address Behavioral Health Needs
Penalty
Summary
The facility failed to provide necessary behavioral health care services for a resident with a history of bipolar disorder, depression, and panic disorder. The resident, admitted in November 2022, exhibited increased depression and difficulty coping with stress, as noted in multiple evaluations. Despite being on risperdal for bipolar disorder, the resident's care plan interventions were not effectively reviewed or revised to address ongoing mood symptoms and behaviors. Observations and interviews revealed that the resident remained isolated in their room, did not participate in activities, and expressed unhappiness. Family members reported the resident's suicidal ideations to the facility, but no mental health evaluation was conducted. Staff members described the resident as verbally and physically aggressive, with no recent onset of these behaviors. The Social Services Director acknowledged the inadequacy of the behavior monitor in tracking mood symptoms and the lack of appropriate interventions for the resident's depression. The facility's failure to refer the resident to an in-house psychiatrist and the ineffective interventions in place contributed to the deficiency. Staff members, including the Social Services Director and LPN Resident Care Manager, recognized the resident's unhappiness and care refusals but did not take sufficient action to address these issues. The facility administrator confirmed that the resident's mood and behavioral needs were not fully addressed, highlighting a significant gap in the provision of necessary behavioral health care services.
Communication Breakdown with Hospice Leads to Delayed Pain Management
Penalty
Summary
The facility failed to establish an effective communication process with the hospice provider, resulting in unmet needs for a resident receiving hospice care. The hospice policy required a coordinated Plan of Care (POC) between the facility and hospice, with the hospice responsible for notifying the facility of changes in care. However, there was a delay in implementing a physician's order for a fentanyl patch, which was intended to manage the resident's pain. The order was given on October 1, 2024, but the patch was not applied until October 5, 2024. Additionally, the patch was placed on the resident's arm instead of the upper chest as directed, and this issue persisted despite communication from the hospice nurse. The resident, who was admitted with a traumatic subdural hemorrhage and was cognitively intact, experienced pain and was enrolled in hospice care. Observations revealed that the fentanyl patch was consistently placed on the resident's arm, contrary to the hospice's instructions. Family members and hospice staff reported communication issues and delays in implementing hospice orders. Staff members were unaware of the specific instructions regarding the placement of the fentanyl patch, indicating a breakdown in communication and adherence to the hospice care plan.
Resident Dignity Compromised by Staff's Use of Homophobic Slur
Penalty
Summary
The facility failed to ensure a resident was treated in a dignified manner and free from derogatory slurs. This deficiency involved a resident who was admitted in June 2023 with diagnoses including aftercare for surgical amputation and was assessed as cognitively intact. During a dinner service, the resident overheard a former hospitality aide using a homophobic slur in conversation with other staff members. The resident reported feeling afraid and uncomfortable at the facility due to this incident and expressed concerns about potential retaliation, having experienced similar issues in the past. The facility's investigation revealed that multiple staff members confirmed the use of the derogatory term by the former hospitality aide. The resident was placed on alert monitoring for psychosocial well-being following the incident, with no negative outcomes reported. Interviews with staff and the resident confirmed the occurrence of the event, although the former hospitality aide did not recall using the specific slur. The facility administrator stated an expectation for all residents to be treated with dignity and respect, free from homophobic slurs.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to ensure a safe and comfortable environment for its residents, as evidenced by the condition of a resident's bed mattress and the presence of offensive odors throughout the facility. A resident, admitted in 2010 with diagnoses including abnormal posture, cognitive deficits, and depression, was observed to have a bed mattress with a large divot covering approximately three-quarters of the mattress, making it difficult for the resident to move. Staff members, including CNAs and the Maintenance Director, confirmed the mattress was old, broken down, and needed replacement. Additionally, the facility was reported to have offensive odors, particularly of urine, in various areas, including residents' bathrooms and hallways. Complaints were received by the State agency regarding the cleanliness and odor issues. Observations confirmed the presence of strong urine smells in specific rooms and hallways, with cracked tiles and inadequate sealing around toilets contributing to the problem. Despite housekeeping efforts, the Maintenance Director and Administrator acknowledged the persistent odor issues and the need for repairs to address the cracked tiles and sealing problems.
Discrepancy in Resident's POLST and Code Status
Penalty
Summary
The facility failed to ensure the correct Physician Orders for Life-Sustaining Treatment (POLST) was readily available and accessible for a resident, leading to a discrepancy in the resident's code status. The resident, admitted in October 2023 with chronic obstructive pulmonary disease and cognitively intact, had two signed POLST documents with conflicting instructions. The POLST dated October 4, 2023, indicated the resident wished to be full code, while the POLST dated October 27, 2023, indicated a Do Not Resuscitate (DNR) status. A public complaint in June 2024 alleged the resident wanted to be full code, but the POLST was filled out incorrectly. Interviews with staff confirmed the resident's code status was documented as DNR, which was not accurate according to the resident's wishes. The discrepancy was confirmed by the Director of Nursing Services (DNS) on October 29, 2024.
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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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