Regency Redmond Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Redmond, Oregon.
- Location
- 3025 Sw Reservoir Drive, Redmond, Oregon 97756
- CMS Provider Number
- 385230
- Inspections on file
- 19
- Latest survey
- January 16, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Regency Redmond Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
The facility did not staff an RN for eight consecutive hours per day for nine days, risking unmet assessment needs for residents. This was confirmed through staff reports and payroll records, highlighting a failure to meet staffing requirements.
The facility did not follow therapeutic diet protocols, as a cook prepared meals without using recipes or diet spreadsheets, and lacked training on these tools. Nutritionally Enhanced Meals were not properly enhanced, relying instead on supplements. The RD's audits did not verify the use of required diet tools, and recipes were sourced from the internet due to a lack of facility-provided options.
A resident with palliative care and diabetes was found without their call light within reach on two occasions, despite a care plan requiring immediate response to pain relief needs. A CNA admitted to neglecting this responsibility, and an RNCM confirmed the oversight.
A resident with a stroke diagnosis reported a grievance during a care conference, stating that a CNA refused to assist them. The facility failed to document or follow up on this grievance, as confirmed by the Social Services Director and other staff members who did not recall the incident. This oversight placed residents at risk for unresolved grievances.
A facility failed to create a person-centered care plan for a resident with brain damage, quadriplegia, and a feeding tube. The care plan inaccurately described the resident as independent in toileting and transferring, despite needing a mechanical lift, and included irrelevant interventions. A registered nurse case manager acknowledged the care plan was not individualized, placing the resident at risk for unmet needs.
The facility failed to properly assess and manage pressure ulcers for three residents, leading to worsening conditions. One resident developed Stage 2 ulcers on both ankles without proper investigation or care. Another resident's coccyx pressure area was not monitored, progressing to a Stage 4 ulcer with tunneling, and old packing was found in the wound. A third resident had a misidentified Stage 2 ulcer and undocumented blisters on the thigh.
A facility failed to provide trauma-informed care for a resident with PTSD and anxiety. The resident's psychosocial assessment inaccurately reported no trauma issues, and the care plan lacked interventions for PTSD. Observations showed the resident was often sleeping during the day, with staff noting nighttime anxiety and withdrawn behavior. Staff interviews revealed a lack of awareness and specific interventions for the resident's PTSD, highlighting the need for tailored care.
A facility failed to monitor side effects of psychotropic medications for a resident with chronic mental health diagnoses, who was administered olanzapine, valproic acid, and clonazepam. Staff were expected to document side effects on the TAR and in Progress Notes, but the order was entered as PRN, preventing alerts for monitoring and documentation.
The facility did not administer flu and pneumonia vaccines to two residents who had consented, despite their documented consent. Both residents, admitted with diabetes, had no records of receiving the vaccines, which was confirmed by staff.
A facility failed to report an alleged abuse incident involving a resident with a stroke diagnosis. An LPN noted potential harm during suctioning, and multiple staff members were aware of a CNA holding the resident's hands down during care. Despite this, the incident was not reported to administration until much later, and a Facility Reported Incident was not submitted at the time.
The facility failed to follow diabetic care protocols for a resident with low blood glucose and performed unsafe suctioning on another resident, leading to bleeding. The diabetic protocol was not implemented when a resident's blood glucose was critically low, and documentation was lacking. Another resident, with a communication deficit, was suctioned too deeply, causing bleeding, and was reportedly restrained during the procedure.
The facility failed to follow care plans for fall safety and post-fall assessments for two residents. One resident with a stroke diagnosis experienced multiple unwitnessed falls, with incomplete neurological assessments. Another resident with Parkinson's disease was left unattended on the toilet due to poor staff communication, resulting in a fall and hematoma. These incidents highlight deficiencies in supervision and adherence to care plans.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to staff a registered nurse (RN) for eight consecutive hours per day, seven days a week, for nine out of 60 days reviewed. This deficiency was identified through a review of Direct Care Staff Daily Reports and payroll records, which showed that on specific dates, there was no RN coverage for the required duration. The absence of RN coverage on these days placed residents at risk for unmet assessment needs. The facility's administrator confirmed the lack of RN presence on the specified dates, acknowledging the failure to meet the staffing requirement.
Failure to Follow Therapeutic Diet Protocols
Penalty
Summary
The facility failed to adhere to therapeutic diet protocols for residents, as observed in the kitchen operations. On August 15, 2024, a cook, identified as Staff 14, was seen preparing lunch without using recipes or therapeutic diet spreadsheets for portion control or meal substitutions for residents on therapeutic diets. Staff 14 admitted to not receiving training on diet spreadsheets since her hiring nearly a year ago. Additionally, when Nutritionally Enhanced Meals (NEM) were ordered, the foods were not enhanced as required; instead, nutritional supplements were provided as ordered by the Registered Dietitian (RD). The Dietary Manager, Staff 13, revealed that recipes used in the kitchen were sourced from the internet due to the absence of facility-provided recipes. Furthermore, the RD, identified as Staff 15, confirmed that her audits did not include checking the use of diet spreadsheets and system recipes. She acknowledged that system recipes with therapeutic diet spreadsheets should be used and that foods should be enhanced daily with extra calories to meet NEM diet orders.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that call lights were within reach for a resident, which placed them at risk for unaddressed needs. The resident, who was admitted with diagnoses including palliative care and diabetes, had a care plan indicating that staff should respond immediately to their need for pain relief. On two separate occasions, the resident was observed in bed without their call light within reach. On the first occasion, a CNA admitted to neglecting to ensure the call light was accessible after providing care. On the second occasion, the RNCM confirmed that the call light should have been within reach, acknowledging the oversight.
Failure to Address Resident Grievance
Penalty
Summary
The facility failed to address a grievance reported by a resident who was admitted in June 2021 with a diagnosis of a stroke. On November 20, 2023, during an interdisciplinary conference, the resident reported that a CNA refused to assist them, and the resident care manager was supposed to follow up on this concern. However, the Social Services Director, who maintained all grievances, stated that there was no record of a grievance for this concern. Additionally, the staff responsible for reviewing the schedule and addressing grievances did not recall the resident's grievance. This lack of follow-up and documentation placed residents at risk for unresolved grievances.
Failure to Develop Person-Centered Care Plan for Resident with Quadriplegia
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident who was admitted with diagnoses including brain damage, quadriplegia, and a feeding tube. The care plan, dated the same day as the resident's admission, contained several inaccuracies and inconsistencies. For instance, it incorrectly stated that the resident was independent in toileting and transferring, despite the resident's quadriplegia and reliance on a mechanical lift for transfers. Additionally, the care plan mentioned the resident's ability to eat independently, although the resident received nourishment and medications through a feeding tube. The care plan also included interventions that were not applicable to the resident's condition, such as assisting the resident in choosing clothing to enhance self-dressing, despite the resident's quadriplegia. These inaccuracies indicate that the care plan was not individualized or person-centered, as acknowledged by a registered nurse case manager during an interview. The lack of a tailored care plan placed the resident at risk for unmet needs, as the plan did not accurately reflect the resident's capabilities and required assistance.
Failure to Properly Assess and Manage Pressure Ulcers
Penalty
Summary
The facility failed to accurately assess, investigate, and care plan pressure ulcers for three residents, leading to a risk of worsening conditions. Resident 15, admitted with no pressure ulcers, developed Stage 2 pressure ulcers on both ankles. The facility did not initially investigate the wounds, and staff were unaware of the necessary care. Observations showed that the resident was not repositioned or provided with body pillows as required, and staff misidentified the wounds as skin tears initially. Resident 27 was admitted with a pressure area on the coccyx, which was not properly monitored or documented for over three months. The resident developed a deep tissue pressure injury that progressed to a Stage 4 pressure ulcer with significant tunneling. The facility failed to conduct weekly wound assessments, and old packing was found in the wound during a wound clinic visit, causing the resident extreme pain. Staff were unclear about the wound care orders and did not document tunneling measurements. Resident 28, with bilateral above-knee amputations, had a Stage 2 pressure ulcer misidentified as Stage 3. Additionally, the resident had multiple blisters on the right thigh that were not documented or treated. The facility's documentation did not reflect the resident's actual skin condition, and staff failed to apply dressings to the open areas as reported by the resident.
Failure to Implement Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to assess and implement trauma-informed care interventions for a resident diagnosed with PTSD and anxiety. Upon admission in December 2023, the resident's psychosocial history and discharge plan assessment inaccurately indicated no trauma, mood, or behavior issues. The care plan revised in July 2024 did not include any focus or interventions related to the resident's PTSD, despite the resident's history and diagnosis. Observations in August 2024 revealed the resident was often in bed sleeping during the day, with staff noting the resident was awake most of the night and had withdrawn behavior and anxiety, which were believed to be related to PTSD. Staff interviews highlighted a lack of awareness and specific interventions for the resident's PTSD. A registered nurse noted that the resident only interacted with select staff and expressed concerns about the absence of monitoring related to the resident's PTSD. The Social Services Director acknowledged the psychosocial assessment was inaccurate due to a lack of awareness of the PTSD diagnosis at admission and confirmed that the care plan was not tailored to the resident's behaviors, indicating a need for specific interventions for PTSD.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to monitor side effects of psychotropic medications for one of the sampled residents, placing them at risk for adverse medication reactions. The resident, admitted in May 2017 with chronic mental health diagnoses, was administered scheduled olanzapine, valproic acid, and clonazepam in July and August 2024. However, there was no documentation indicating that the side effects of these medications were monitored. Staff 3, an LPN, stated that staff were supposed to document any side effects on the Treatment Administration Record (TAR) and in the Progress Notes if side effects were observed. Staff 4, an RNCM, explained that the psychotropic medication side effects were supposed to be entered as a scheduled nursing task, but the order was entered as PRN, which did not alert staff to monitor and document any side effects.
Failure to Administer Vaccines to Consenting Residents
Penalty
Summary
The facility failed to ensure that flu and pneumonia vaccines were administered to two residents who had consented to receive them, placing them at risk for respiratory infections. Resident 7, admitted in April 2017 with a diagnosis of diabetes, consented to a pneumonia vaccine on May 4, 2024, but there was no documentation indicating the vaccine was administered. Staff 30 confirmed that the vaccine was not given. Similarly, Resident 15, admitted in December 2023 with a diagnosis of diabetes, consented to a flu vaccine on December 19, 2023, but there was no documentation of administration. Staff 30 also verified that the flu vaccine was not administered to Resident 15.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that allegations of abuse were reported to administration for a resident who was admitted in January 2013 with a diagnosis of stroke. On July 31, 2023, an agency LPN noted that a nurse from the previous shift may have inserted a suction tip too far into the resident's throat, resulting in blood in the suction tubing. On September 23, 2024, a complainant reported to the state agency that facility staff were aware of an incident where a CNA held the resident's hands down while a nurse suctioned the resident's secretions. Multiple staff members, including a former CNA and anonymous staff, confirmed awareness of the incident but failed to report it to administration. The regional nurse stated that any concerns of this nature should be reported and investigated. However, the administrator was only made aware of the allegation on August 14, 2024, and confirmed that a Facility Reported Incident (FRI) was not submitted at the time of the initial incident.
Deficiencies in Diabetic Care and Suctioning Practices
Penalty
Summary
The facility failed to provide appropriate care for two residents, leading to deficiencies in their treatment. Resident 7, who was admitted with a diagnosis of diabetes, had a critical blood glucose level of 48 recorded on the Diabetic Administration Record. Despite the facility's protocol to implement hypoglycemic interventions when blood glucose levels fall below 60, there was no documentation or evidence that such interventions were provided. Staff 4 confirmed that the protocol was not followed, and the resident's clinical record lacked any indication of the necessary actions being taken. Resident 85, admitted with a diagnosis of stroke, experienced unsafe suctioning practices. The resident, who had a communication deficit and was sometimes resistive to care, was reportedly suctioned too deeply, resulting in blood being observed in the suction tubing. A progress note indicated that a nurse might have inserted the suction tip too far, and hospice staff noted dried blood in the resident's mouth. An anonymous staff member reported hearing that a CNA held the resident's hands down during the procedure, which led to bleeding. Staff 2, the Assistant DNS, did not recall any incident related to this resident's care.
Failure to Follow Fall Safety Care Plans and Conduct Post-Fall Assessments
Penalty
Summary
The facility failed to ensure staff followed the care plan related to fall safety and ascertain post-fall injuries for two residents, leading to deficiencies in supervision and accident prevention. Resident 26, admitted with a stroke diagnosis, experienced multiple unwitnessed falls. On one occasion, a neurological assessment was not completed as scheduled, and on another, there was no documentation of the assessment. Despite sustaining a hematoma during a fall, the required neurological checks were not fully conducted, indicating a lapse in following the care plan and documenting post-fall assessments. Resident 10, diagnosed with Parkinson's disease and a history of repeated falls, was identified as a fall risk requiring assistance during toileting. However, due to poor communication between staff during a shift change, Resident 10 was left unattended on the toilet, resulting in a fall and a hematoma. The care plan explicitly stated that the resident should not be left alone, yet this directive was not followed, leading to the incident. The miscommunication between staff members contributed to the failure to provide adequate supervision. These incidents highlight the facility's failure to adhere to established care plans and protocols for fall prevention and post-fall assessments. The lack of proper documentation and communication among staff members resulted in residents being placed at risk for falls and injuries. The deficiencies in supervision and adherence to care plans were evident in both cases, underscoring the need for improved staff training and communication to prevent similar occurrences in the future.
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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