Regency Care Of Rogue Valley
Inspection history, citations, penalties and survey trends for this long-term care facility in Grants Pass, Oregon.
- Location
- 1710 Ne Fairview Avenue, Grants Pass, Oregon 97526
- CMS Provider Number
- 385064
- Inspections on file
- 20
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Regency Care Of Rogue Valley during CMS and state inspections, most recent first.
The facility failed to maintain safe water temperatures, with two residents experiencing excessively hot water in their rooms, posing a risk for burns. Despite weekly checks, the Maintenance Director had not been informed of any concerns, yet temperatures were recorded at 125 and 126 degrees Fahrenheit.
The facility failed to address residents' concerns about cold food, as observed during a Resident Council meeting and through interviews. Residents reported that staff were not allowed to reheat food, and the Dietary Manager confirmed that food handled by residents could not be reheated due to cross-contamination risks. Despite having an additional meal available, the facility did not ensure food was served at an appetizing temperature, leading to dissatisfaction among residents with chronic conditions and nutritional needs.
A resident with paralysis and cognitive impairment expressed the importance of choosing activities, preferring pet interaction and reading. Despite a care plan addressing activity involvement risks, the resident received minimal 1:1 activities and no reading materials. Observations showed the resident often in bed with closed blinds, lacking engagement. Staff acknowledged infrequent pet visits and the availability of an unused audible book player, highlighting the facility's failure to provide meaningful activities.
A resident with dementia and a history of MASD developed a Stage 3 pressure ulcer on the coccyx. Despite worsening conditions and new red spots indicating potential Stage 1 ulcers, the facility failed to revise the treatment plan. Staff focused on the original wound, neglecting the deteriorating surrounding skin, leading to a significant increase in wound size due to adhesive irritation.
A facility failed to implement a recommended RA program for a resident with paralysis, leading to a lack of documented care for maintaining ROM and mobility. Despite a PT discharge summary recommending the program, it was not included in the care plan, and staff interviews revealed a lack of communication and follow-through.
A resident with a history of stroke experienced delays in receiving prescribed respiratory care and diagnostic results. A PRN nebulizer was ordered by an NP for shortness of breath but was not started until two days later. Additionally, a chest x-ray ordered due to chest pain was completed but not received by the facility until over two weeks later. An RN acknowledged the delays but was unsure of the reasons.
A facility failed to monitor a resident's thyroid hormone levels after administering Synthroid, a medication to increase thyroid levels. The resident, admitted with obesity, had their last TSH test in November 2022, which was within the therapeutic range. However, no further TSH tests were documented, despite staff indicating that such tests were usually conducted annually. This oversight placed the resident at risk for a non-therapeutic medication regimen.
A resident with depression was not informed of changes to their medication regimen, resulting in a lack of informed consent. The resident, who was cognitively intact, had their antidepressant dosages reduced without their knowledge. Despite a provider note indicating no unaddressed concerns, there was no documentation of notification in the resident's chart, which was confirmed by the Social Services Director.
Unsafe Water Temperatures in Resident Rooms
Penalty
Summary
The facility failed to maintain safe water temperatures for two residents, placing them at risk for burns. Resident 27, who was cognitively intact and admitted with a wedge compression fracture, reported using the sink to wet their hair. Upon testing, the hot water temperature in Resident 27's room was found to be 125 degrees Fahrenheit, which was acknowledged by the Maintenance Director as needing adjustment. Similarly, Resident 88, also cognitively intact and admitted following hip surgery, experienced excessively hot water in their bathroom. The surveyor noted the water was hot to the touch, and the resident confirmed the water was very hot if not adjusted carefully. The Maintenance Director measured the water temperature at 126 degrees Fahrenheit and noted that the hot water heater was located adjacent to Resident 88's bathroom. Despite performing weekly water temperature checks, the Maintenance Director had not received any reports of concerns regarding high water temperatures in resident rooms.
Failure to Address Cold Food Concerns
Penalty
Summary
The facility failed to address concerns regarding proper food temperatures for residents, as observed during a Resident Council meeting and through interviews with staff and residents. During the meeting, a majority of the residents expressed that staff were not allowed to warm or address cold food concerns. The Dietary Manager stated that the kitchen had one additional meal available if a resident requested warmer food, but food handled by a resident could not be reheated due to cross-contamination risks. The Administrator was unaware of reports related to residents' cold food and acknowledged the need for staff education on this issue. Resident 9, who has chronic pain and dementia, was observed eating lunch with frozen strawberries and expressed frustration about staff not addressing cold food issues. Resident 25, with a history of stroke and malnutrition, reported that staff did not reheat meals or beverages, affecting her/his food intake. Staff confirmed that they were not allowed to reheat food once touched by a resident, but the kitchen could provide new servings if requested. Despite complaints from residents, the facility did not have a clear process to ensure food was served at an appetizing temperature, leading to dissatisfaction and potential nutritional concerns.
Failure to Provide Meaningful Activities for Resident
Penalty
Summary
The facility failed to provide a meaningful activity program for a resident who was admitted with a diagnosis of paralysis and was cognitively impaired. The resident expressed that choosing activities was very important, with a preference for interacting with pets and reading. Despite these preferences, the care plan, which was revised, indicated a risk for little activity involvement due to physical and cognitive limitations. The plan included offering group activities, 1:1 visits, and providing reading material. However, the resident preferred self-directed activities and did not want to participate in group activities, with only one 1:1 activity provided in the previous quarter. Observations showed the resident often remained in bed with closed blinds and no engagement in activities like music or television. Staff interviews revealed that the resident did not enjoy television but liked talking and joking. The Activity Supervisor acknowledged the infrequent visits by a volunteer with a dog and the availability of an audible book player, which was not offered to the resident. The resident's activity log indicated participation in independent activities, primarily snacks, with no documented 1:1 visits or reading activities. The resident's family visits were infrequent, and staff noted the resident's blinds were often shut, although occasionally opened upon request. These findings highlight the facility's failure to provide adequate and meaningful activities tailored to the resident's preferences and needs.
Failure to Revise Pressure Ulcer Treatment
Penalty
Summary
The facility failed to properly assess and revise treatments for a pressure ulcer in a resident, leading to a deficiency. The resident, admitted in March 2017 with diagnoses including dementia and failure to thrive, was at risk for pressure ulcers and had recurrent Moisture Associated Skin Damage (MASD). Despite interventions, the resident developed a facility-acquired Stage 3 pressure ulcer on the coccyx. Initial wound care orders included the application of calcium alginate, marathon, and foam dressing. However, the wound deteriorated over time, with the surrounding skin becoming denuded and the wound size increasing significantly due to adhesive irritation. Staff interviews revealed that the wound treatment was not adjusted despite the worsening condition of the surrounding skin. An LPN noted the appearance of new red spots near the wound, indicating potential Stage 1 pressure ulcers, but the RN-Patient Care Coordinator focused solely on the original wound. The Director of Nursing Services acknowledged that the wound should have been assessed as two separate wounds, and a new treatment regimen should have been considered when the surrounding skin began to deteriorate.
Failure to Implement Restorative Assistance Program
Penalty
Summary
The facility failed to provide a restorative assistance (RA) program for a resident who was admitted with a diagnosis of paralysis. The resident, who had impaired cognition and was bed-bound, required assistance with activities of daily living (ADLs) and used a mechanical lift for transfers. A physical therapy discharge summary recommended an RA program to maintain and improve the resident's range of motion (ROM) and mobility, which was crucial to prevent contractures and muscle wasting. However, the care plan did not include this RA program, and there was no documentation in the clinical record indicating its implementation. Interviews with facility staff revealed a lack of communication and follow-through regarding the RA program. The Therapy Director confirmed that an RA program was established but not documented in the RA book. The RA staff member stated he had never worked with the resident, and the RN Patient Care Coordinator mentioned she was not provided with a referral to implement the RA program. The resident had a history of refusing therapy, but there was no evidence that the RA program was re-evaluated or implemented as recommended by the therapy discharge summary.
Delayed Respiratory Care and Diagnostic Results
Penalty
Summary
The facility failed to provide timely respiratory care and ensure diagnostic results were available promptly for a resident with a history of stroke. The resident was assessed by a nurse practitioner (NP) for shortness of breath, and a PRN nebulizer was ordered on October 8, 2024. However, the nebulizer treatment was not initiated until October 10, 2024. Additionally, the resident experienced chest pain with deep breaths on October 11, 2024, leading to an order for a chest x-ray. Despite the x-ray being completed on the same day, the results were not faxed to the facility until October 28, 2024. Staff 4, an RN Patient Care Coordinator, acknowledged the delay in receiving the x-ray results and was unsure why the nebulizer treatment was not started on the day it was prescribed.
Failure to Monitor Thyroid Hormone Levels
Penalty
Summary
The facility failed to monitor a resident's thyroid hormone level, specifically the TSH (thyroid stimulating hormone) test, for a resident who was administered Synthroid to increase thyroid levels. The resident was admitted in August 2021 with a diagnosis of obesity and began receiving Synthroid in October 2021. The last recorded TSH test was conducted in November 2022, and the results were within the therapeutic range. However, no further TSH test results were documented in the resident's clinical record after that date. During interviews, staff indicated that TSH levels were typically checked annually, but no documentation was provided to confirm that this was done for the resident in question. The lack of monitoring placed the resident at risk for a non-therapeutic medication regimen, as there was no evidence of ongoing assessment of the resident's thyroid function after November 2022.
Failure to Notify Resident of Medication Changes
Penalty
Summary
The facility failed to notify a resident prior to changing the administration of their medication, resulting in a lack of informed consent. Resident 139, who was admitted in 2024 with a diagnosis of depression, was cognitively intact according to the Admission MDS. The resident's initial medication orders included Citalopram 60mg and Imipramine 50mg at bedtime. However, a subsequent provider order reduced these dosages to Citalopram 20mg and Imipramine 25mg at bedtime. Despite a provider note indicating that the resident had no unaddressed concerns, there was no documentation in the resident's chart confirming that they were informed of these medication changes. On a later date, Resident 139 expressed that they were unaware of the medication reduction, which had been a successful treatment for their depression for years. This was confirmed by the Social Services Director/Admissions, who verified that there was no additional information in the resident's chart regarding notification of the medication changes.
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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