Regency Albany
Inspection history, citations, penalties and survey trends for this long-term care facility in Albany, Oregon.
- Location
- 805 19th Avenue Se, Albany, Oregon 97321
- CMS Provider Number
- 385220
- Inspections on file
- 22
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Regency Albany during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was found in another resident's room engaged in inappropriate sexual contact, with no memory of the event and exhibiting unusual behavior afterward. Despite the incident and the other resident's history of inappropriate conduct, the facility did not implement or document any interventions to ensure safety, and the family was not promptly notified.
A resident's allegations of sexual and verbal abuse were not reported to the State Survey Agency within the required two-hour timeframe. The incidents were reported several days after they occurred, and the facility administrator confirmed the delay in reporting.
The facility failed to implement proper infection control and sanitation practices for residents with C-Diff and other infections. A resident with C-Diff was not placed on contact precautions timely, and staff used ineffective cleaning products. Another resident with a pressure ulcer received unsanitary wound care. Staff also failed to use PPE and proper hand hygiene during medication administration and high-contact care activities.
Two residents experienced verbal abuse by staff in a LTC facility. One resident, with anxiety and depression, was left feeling stripped of dignity after a CNA refused to get assistance during care. Another resident, with cerebral palsy, faced aggressive behavior from the Kitchen Manager during a grievance discussion. Witnesses confirmed the inappropriate conduct, leading to a delayed abuse investigation.
The facility failed to document and follow up on advance directives for several residents, including those with leg fractures, open wounds, and malnutrition. Despite providing advance directive packets during care conferences, there was no follow-up to ensure completion or documentation, placing residents at risk of not having their healthcare decisions honored.
The facility did not provide a homelike dining environment in three dining rooms. Meals were left on trays, and tables lacked decorations and tablecloths. The administrator acknowledged that meals should feel like home and trays should be removed unless requested by residents.
Facility staff failed to follow professional standards for medication administration and wound care, affecting four residents. An LPN administered medications late and without checking blood pressure, while another staff member provided inadequate wound care by not sanitizing hands or changing gloves. Additionally, a resident did not rinse their mouth after using an inhaler, and medications were given without proper timing or checks.
A long-term care facility reported a medication error rate of 18.92%, with errors including late administration, failure to check blood pressure, improper handling of medications, and not following specific medication instructions. These incidents involved residents with heart disease, respiratory failure, and thyroid disorder, and were attributed to a lack of guidance for LPNs on handling late medication administration.
A resident with Parkinson's disease and hand contractures was unable to use the facility's call light system, leading to unmet hydration needs. Despite a revised care plan, the resident had to yell for assistance, as confirmed by staff. The care plan lacked interventions for the resident's inability to use the call light and the need for frequent fluid offers, which was acknowledged by the Resident Care Manager.
A resident with bipolar disorder was inaccurately assessed regarding their discharge preferences. Despite the 9/28/24 Annual MDS indicating the resident did not want to discuss leaving the facility, interviews in November revealed the resident's desire to discharge to a home in Corvallis or Philomath. Staff confirmed the MDS information was incorrect, and the Regional Nurse acknowledged the error.
A resident with bipolar disorder was not provided with the necessary mental health evaluations as indicated by a PASRR Level 1 form. Despite the form highlighting serious mental illness indicators, the facility did not complete further evaluations, as acknowledged by the Social Service Manager.
A resident did not receive Catholic communion as scheduled due to a COVID outbreak, and the facility failed to document spiritual activity participation. The resident, with anxiety and depression, was cognitively intact and had minimal participation in spiritual activities over several months.
A facility failed to follow physician orders for insulin administration for a resident with diabetes. The resident had orders for 13 units of Humalog insulin before each meal, to be held if the CBG level was less than 100. However, an LPN held the insulin on two occasions when the CBG levels were above 100, due to a misunderstanding of standing orders. The Regional Nurse confirmed that the physician's orders should have been followed.
Two residents experienced deficiencies in pressure ulcer care and infection control. A resident's blisters were not documented as Stage 2 pressure ulcers, and another resident's wound care was compromised by an LPN's failure to maintain proper infection control practices, including not sanitizing hands and using soiled gloves and scissors.
The facility failed to ensure a safe environment for two residents, leading to potential injury risks. A resident with hoarding behaviors was injured by a falling bedside table, which was not promptly evaluated. Another resident, requiring fall mats due to chronic heart failure and dementia, did not have them in place as per their care plan, and the LPN was unaware of this omission.
A facility failed to provide and document catheter care for a resident with a Stage 4 pressure ulcer. The resident was observed with blood in the catheter tubing, which they stated was normal after a catheter change. However, there was no documentation in the Treatment Administration Record or Nursing Progress Notes for catheter care, such as flushing, cleaning, or changing the catheter. An LPN confirmed the lack of documentation in the resident's electronic record.
The facility failed to provide proper respiratory care for two residents, leading to potential infection risks. A resident's CPAP mask was stored improperly with a used tissue nearby, while another's BiPAP machine was unsanitarily placed on a nightstand and bedrail. Staff acknowledged the inadequate storage practices and policy shortcomings.
A resident with cerebral palsy, dependent on staff for toileting, reported that caregivers made derogatory comments about the smell of their feces, leading to feelings of embarrassment and shame. The incident was not documented in the resident's progress notes, and the facility administrator confirmed the termination of the involved CNA's contract due to the inappropriate comment.
A facility failed to timely report an abuse allegation to the SSA for a resident with anxiety and depression. The incident occurred on a weekend, and the report was delayed due to a holiday, being sent the following Tuesday. The Administrator could not recall the report timing, and the DNS confirmed the delay, placing residents at risk.
Failure to Protect Cognitively Impaired Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment, including Alzheimer's dementia and aphasia, from sexual abuse by another resident. The incident occurred when a CNA found the cognitively impaired resident in another resident's room, with her/his hands on the other resident's genitals. The resident was redirected to her/his own room and exhibited unusual behavior afterward, such as refusing care and being naked, which was not typical for this resident. The resident had no memory of the incident, and interviews confirmed the resident's inability to consent due to cognitive loss. The other resident involved had a history of making inappropriate comments and watching pornography in the facility. Despite the incident, a review of the medical record and care plan revealed that no interventions were implemented to ensure the safety of the resident following the event. There was no documentation of new safety measures or care plan updates addressing the incident or the behavior of the other resident. Additionally, the family was not promptly notified of the incident, and the administrator acknowledged that appropriate interventions were not put in place due to delayed reporting.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse and an allegation of verbal abuse involving one resident to the State Survey Agency within the required two-hour timeframe. Specifically, the incident of alleged sexual abuse occurred on 9/19/25 at 9:30 PM but was not reported until 9/22/25 at 2:51 PM, and the incident of alleged verbal abuse occurred on 7/19/25 at 12:41 PM but was not reported until 7/21/25 at 2:30 PM. These delays in reporting were confirmed by the facility administrator during an interview, who acknowledged that the incidents were not reported in a timely manner as required.
Inadequate Infection Control and Sanitation Practices
Penalty
Summary
The facility failed to implement transmission-based precautions and proper sanitation procedures for residents diagnosed with Clostridium difficile (C-Diff) and other infections. Resident 30, who was admitted with C-Diff, was not placed on appropriate contact precautions until several days after admission. Staff used ineffective cleaning products, such as Mycolio disinfectant wipes, which are not effective against C-Diff spores. Additionally, staff were observed not following proper hand hygiene and PPE protocols, leading to potential cross-contamination. Resident 10, who had a Stage 4 pressure ulcer, received wound care that did not adhere to sanitary practices. The staff member performing the wound care did not sanitize her hands before donning gloves, used soiled gloves to handle clean dressing supplies, and did not establish a clean field for the procedure. This lack of proper infection control measures could have compromised the resident's wound healing process. Other residents, such as Resident 19 and Resident 27, also experienced lapses in infection control. Staff were observed handling medications without sanitizing hands or using gloves, and failing to use PPE during high-contact care activities. Resident 195, who had a history of C-Diff, was not placed on contact precautions despite having multiple loose stools documented. These deficiencies highlight a systemic issue in the facility's infection prevention and control practices.
Removal Plan
- The hydration cart and vital sign equipment was sanitized to prevent the spread of infection.
- Current staff on shift were re-educated on transmission-based precautions relative to C-Diff per the CDC guidelines. Soap and water were reinforced as the standard for hand hygiene. Additional education was provided to include donning and doffing of PPE.
- Nurse management would complete ongoing Infection Control rounds on all three shifts, and then conduct random audits on all three shifts.
- New admissions to the facility would be reviewed by the Regional Nurse and IP to ensure that appropriate Infection Control measures were implemented, and Kardex and Care plans updated.
- Resident 30 had her/his room deep-cleaned as well as linens changed. Resident 30 declined a shower but accepted a full bed bath.
- Facility staff would be trained on providing hydration while facility residents were on transmission-based precautions including direction to obtain new water pitchers with each hydration pass.
- Current residents on transmission-based precautions had donning and doffing procedures added to the signage on the residents' doors for easy staff reference.
- Residents on transmission-based precautions were provided individual vital sign equipment while on transmission-based precautions.
- The facility IP would complete further training presented by Oregon Care partners on transmission-based precautions.
- Facility equipment for those on transmission-based precautions would be sanitized utilizing the Clorox Bleach Germicidal wipes with a contact time of three minutes. Education was provided to facility staff on cleansing techniques.
- The Regional Nurse would review the Infection Control portal to ensure that infections were care planned and appropriate precautions were implemented.
- A root cause analysis would be completed by the Governing Body and brought to the facility QAPI committee for review.
- The facility Executive Director was responsible for ensuring on-going compliance with the plan.
- Other residents in the facility with orders for transmission-based precautions were reviewed to validate they were placed on appropriate transmission-based precautions.
- Residents admitted to the facility were to be reviewed to validate that transmission-based precautions were implemented as appropriate, and PPE was available in the facility.
- Findings of the above audits would be reviewed with the medical director.
Verbal Abuse Incidents in LTC Facility
Penalty
Summary
The facility failed to protect residents from verbal abuse by staff, as evidenced by incidents involving two residents. Resident 18, who was admitted with anxiety and depression, experienced an incident where a former agency CNA, Staff 38, refused to get assistance while helping the resident off a bedpan, resulting in a spill. Despite Resident 18's repeated requests for help, Staff 38 continued to clean the resident while making inappropriate comments, leaving the resident feeling stripped of dignity. The care plan for Resident 18 indicated a need for two-person assistance with bed mobility, which was not followed, leading to the incident. In another incident, Resident 1, who has cerebral palsy and is cognitively intact, reported a grievance after a confrontation with Staff 22, the Kitchen Manager. During a discussion about a meal that Resident 1 believed caused diarrhea, Staff 22 became defensive, raised his voice, and made aggressive comments. Witnesses, including other residents and staff, confirmed that Staff 22's behavior was inappropriate and could be considered verbal abuse. The incident was initially not recognized as abuse, but further discussions in a Resident Council meeting led to an investigation. Both incidents highlight a failure to adhere to expected standards of care and communication, resulting in residents feeling unsafe and disrespected. The facility did not place Resident 18 on alert for psychosocial harm following the incident, and there was a delay in recognizing the verbal abuse experienced by Resident 1. These deficiencies indicate a lack of appropriate response to allegations of abuse and a failure to protect residents from harm.
Failure to Document and Follow Up on Advance Directives
Penalty
Summary
The facility failed to obtain and document advance directives for four out of five sampled residents, which placed them at risk of not having their healthcare decisions honored. Resident 8 was admitted with a leg fracture and was noted to have a POLST that was not signed by a physician, and there was no advance directive in the electronic record despite indications otherwise. Resident 30, admitted with an open wound, was supposed to receive an advance directive booklet, but there was no documentation of this in the progress notes. Similarly, Resident 32, admitted with malnutrition, was expected to have an advance directive brought by a family member, but there was no documentation of this occurring. Resident 20, who was cognitively intact with a BIMS score of 15, had no advance directive documented in their medical record despite multiple care conferences over the course of a year. The Social Services Director, Staff 24, stated that advance directives were reviewed during care conferences, and packets were provided, but there was no follow-up on whether the directives were completed or documented. This lack of follow-up and documentation was consistent across the cases reviewed, indicating a systemic issue in the facility's handling of advance directives.
Failure to Provide Homelike Dining Environment
Penalty
Summary
The facility failed to provide a homelike dining environment in three dining rooms, as observed during a survey. In the Middle dining room, meals were left on delivery trays during the meal, and tables lacked decorations and tablecloths. In the Back dining room, meals were also left on trays, and no tablecloths were present. Similarly, in the Front dining room, meals were left on trays. The facility's administrator acknowledged that meals should feel like home and that trays and plate warmers should be removed unless requested by residents.
Medication and Wound Care Deficiencies
Penalty
Summary
The facility staff failed to adhere to professional standards of practice for medication administration and wound care, affecting four residents. For Resident 9, the LPN administered Losartan late and without checking the resident's blood pressure, despite standing orders to hold the medication if the systolic blood pressure was below 100. The LPN admitted to not receiving guidance on handling late medication administration and acknowledged the oversight. Resident 10, who had a Stage 4 pressure ulcer, received inadequate wound care from the Resident Care Manager. The staff member did not sanitize hands before donning gloves, used contaminated surfaces for clean supplies, and failed to change gloves between handling soiled and clean items. The Regional Nurse confirmed that the staff member had recently completed a wound care class and should have known the correct procedures. For Resident 19, the LPN handled medications with unsanitized hands and did not follow the physician's order to have the resident rinse their mouth after using a Combivent inhaler. Additionally, the LPN relied on outdated blood pressure readings before administering Metoprolol, contrary to the facility's standing orders. Resident 33's medications were administered late, and the LPN did not check blood pressure before giving blood pressure medications. Furthermore, Levothyroxine was given after breakfast, contrary to guidelines that it should be taken on an empty stomach.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in an 18.92 percent error rate. This was due to seven errors out of 37 medication administration opportunities. One incident involved a resident with heart disease who was administered medications one hour and 45 minutes late without a blood pressure check, despite standing orders to hold blood pressure medications if systolic pressure was less than 100. The LPN involved did not receive guidance from management on procedures for running late with medication administration. Another incident involved a resident with respiratory failure, where an LPN failed to sanitize her hands or wear gloves before handling medications and did not ensure the resident rinsed their mouth after using a Combivent inhaler, as per physician orders. Additionally, a resident with heart disease and thyroid disorder received medications late, after breakfast, without a blood pressure check, and contrary to instructions for Levothyroxine to be taken on an empty stomach. The LPN involved was not informed about procedures for late medication administration.
Failure to Provide Appropriate Call Light System for Resident
Penalty
Summary
The facility failed to assess and provide an appropriate call light system for a resident with Parkinson's disease and hand contractures, who was unable to use the button call light. The resident was admitted in February 2020 and had a care plan revised in November 2024, which included the use of a push pad call light within reach due to hand contractures. However, observations on multiple occasions revealed that the resident was unable to use the push pad call light and had to yell for assistance, indicating unmet needs for hydration as the resident expressed thirst and frustration. Staff interviews confirmed that the resident's care needs had increased, and the care plan did not address the resident's inability to use the call light or the need for frequent fluid offers. The Resident Care Manager acknowledged that the resident was not assessed before implementing the new push pad call light, and the care plan lacked necessary interventions to address the resident's fluid and call light needs. This oversight placed the resident at risk for unmet needs and lack of ability to call for assistance.
Inaccurate Assessment of Resident's Discharge Preferences
Penalty
Summary
The facility failed to accurately assess a resident's desire for discharge, leading to a deficiency in the assessment process. The resident, admitted in September 2020 with a diagnosis of bipolar disorder, was documented in the 9/28/24 Annual MDS as not wanting to discuss leaving the facility or returning to the community. However, interviews conducted on 11/4/24, 11/5/24, and 11/6/24 revealed that the resident expressed a desire to discharge to a home in Corvallis or Philomath. Staff members, including the Social Service Manager and Social Service Assistant, confirmed the resident's wish to leave the facility, acknowledging that the information on the 9/28/24 Annual MDS was incorrect. The Regional Nurse also acknowledged the error and indicated that corrections were being made to the MDS.
Failure to Conduct Required Mental Health Evaluations
Penalty
Summary
The facility failed to ensure that a resident with a serious mental illness received the necessary evaluations and care. The resident, admitted in September 2020, had a diagnosis of bipolar disorder. A PASRR Level 1 form dated September 17, 2024, indicated that the resident exhibited serious mental illness indicators and required further evaluation at the nursing facility. However, as acknowledged by the Social Service Manager on November 6, 2024, no further evaluations for mental illness were completed for the resident, leading to a deficiency in meeting the resident's mental health needs.
Failure to Provide Scheduled Spiritual Activities
Penalty
Summary
The facility failed to provide activities of choice for a resident, specifically Catholic communion, which was not received since the beginning of 2024. The resident, admitted in February 2022 with diagnoses including anxiety and depression, was cognitively intact as per a July 2024 Quarterly MDS. Despite Catholic communion being scheduled for November 5, 2024, the resident reported not receiving it. The Activities Director confirmed that no one was able to come in for communion on that date due to a COVID outbreak in the facility and also stated that documentation of when residents received communion was not maintained. The resident's participation in spiritual activities was minimal, with only one recorded instance from August to November 2024.
Failure to Follow Insulin Administration Orders
Penalty
Summary
The facility failed to adhere to physician orders for insulin administration for a resident with diabetes, leading to a deficiency. The resident, admitted in November 2021, had a physician order dated October 2024 for 13 units of Humalog insulin before each meal, with instructions to hold the medication if the capillary blood glucose (CBG) level was less than 100. However, on November 1 and November 6, 2024, the resident's CBG levels were 123 and 110, respectively, and the insulin was incorrectly held by an LPN. The LPN mistakenly believed there were standing orders to hold insulin if the CBG level was at 150 or above and did not seek clarification from the resident's physician. This oversight was acknowledged by the Regional Nurse, who confirmed that physician orders should be followed as written.
Deficiencies in Pressure Ulcer Care and Infection Control
Penalty
Summary
The facility failed to properly assess and treat pressure ulcers for two residents, leading to deficiencies in care. Resident 8, admitted with a leg fracture, developed blisters on the left thigh due to a leg brace. These blisters were not accurately documented as Stage 2 pressure ulcers, as per CDC guidelines, and the incident report was incomplete, lacking input from the CNA who identified the condition. The wound nurse assessed the situation, but the documentation and classification of the blisters were not thorough or accurate. Resident 10, admitted with a Stage 4 pressure ulcer, was at high risk for developing additional ulcers due to factors like malnutrition and incontinence. During a wound care procedure, an LPN failed to maintain proper infection control practices. The LPN did not sanitize hands before donning gloves, used soiled gloves and scissors to handle clean dressings, and did not establish a clean field for the supplies. These actions compromised the sterility of the wound care process, as acknowledged by the LPN and a regional nurse.
Failure to Address Accident Hazards for Residents
Penalty
Summary
The facility failed to maintain an environment free from accident hazards for two residents, leading to potential risks of injury. Resident 17, who was admitted with diagnoses including depression and severe obesity, exhibited hoarding behaviors that were not addressed in a timely manner. On October 27, 2024, Resident 17's bedside table fell on their left shin, causing a small abrasion. Despite an investigation by the Director of Nursing Services (DNS) on October 28, 2024, no predisposing environmental factors were identified, and the table was not evaluated until November 5, 2024. The hoarding issue was only acknowledged on November 7, 2024, indicating a delay in addressing the environmental hazard. Resident 37, admitted with chronic heart failure and dementia, had a care plan dated August 15, 2024, which required fall mats on both sides of their bed. However, observations from November 4 to November 8, 2024, revealed the absence of these fall mats. During an interview on November 8, 2024, the Resident Care Manager (LPN) was unaware of the missing fall mats, despite the care plan's requirements. This oversight in implementing the care plan further contributed to the unsafe environment for Resident 37.
Failure to Document Catheter Care
Penalty
Summary
The facility failed to provide adequate care and services related to catheterization for a resident who was reviewed for catheterization. The resident, who was admitted with a diagnosis including a Stage 4 pressure ulcer, was observed with blood in the catheter tubing. The resident mentioned that blood in the tubing was normal after a catheter change. However, a review of the Treatment Administration Record (TAR) and Nursing Progress Notes for November 2024 revealed no documentation of catheter care, such as flushing, cleaning, or changing the catheter. Additionally, a staff member, identified as the Resident Care Manager-LPN, confirmed that there was no documentation in the resident's electronic record indicating that catheter care was provided.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for two residents, leading to potential risks of respiratory infections. Resident 17, who was admitted with diagnoses including depression and sleep apnea, used a CPAP machine. The facility's policy on equipment sanitation did not specify proper storage for respiratory equipment. Despite a physician's order to clean the CPAP equipment weekly, observations revealed that Resident 17's CPAP mask was improperly stored on a counter with a used tissue nearby. Staff confirmed that the CPAP equipment was stored uncovered with other personal items, acknowledging the inadequacy of the facility's policy and the improper storage practice. Similarly, Resident 28, admitted with respiratory failure and using a BiPAP machine, was observed to have their equipment stored unsanitarily on multiple occasions. The BiPAP machine was found on top of the nightstand, hanging over it, and on the bedrail, all in an unsanitary manner. Staff confirmed the improper storage of the BiPAP mask, which should have been stored in a bag. These observations highlight the facility's failure to ensure proper storage and sanitation of respiratory equipment, as required by their policies and physician orders.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by an incident involving a resident with cerebral palsy who was dependent on staff for toileting. The resident, who was cognitively intact and able to understand others, reported that two caregivers made derogatory comments about the smell of their feces while providing toileting assistance. This incident was not documented in the resident's progress notes, indicating a lack of proper record-keeping regarding the event. The resident expressed embarrassment and reported the incident to the Activities Director, who then informed the facility administrator. The administrator confirmed awareness of the allegation and stated that the contract of the involved agency CNA was terminated due to the inappropriate comment. Despite the CNA's denial of making such comments, other staff members corroborated the resident's account, noting that the resident felt shamed and embarrassed. The incident highlights a failure in maintaining the dignity and respect of the resident, as required by regulatory standards.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to timely report an allegation of abuse to the State Survey Agency (SSA) for a resident who was admitted with diagnoses including anxiety and depression. The incident occurred on August 31, 2024, which was a Saturday, and the following Monday was a holiday. The Facility Reported Incident (FRI) was sent to the SSA on Tuesday, September 3, 2024. During interviews, the Administrator was unable to recall when the FRI was sent, and the Director of Nursing Services (DNS) confirmed the timeline of events. This delay in reporting placed residents at risk for abuse.
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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