Rivers Edge Rehabilitation And Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Sheridan, Oregon.
- Location
- 411 Se Sheridan Road, Sheridan, Oregon 97378
- CMS Provider Number
- 385275
- Inspections on file
- 22
- Latest survey
- February 23, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Rivers Edge Rehabilitation And Care during CMS and state inspections, most recent first.
The facility failed to provide a safe and homelike environment for its residents, as evidenced by dim bathroom lighting, damaged walls, a cracked window, cold water, and a malfunctioning bed. These issues affected several residents, including one with dementia and another with heart failure, leading to unsafe and uncomfortable living conditions. The maintenance staff acknowledged the problems, but repairs were delayed or incomplete.
A facility failed to maintain sanitary food storage in a resident's room refrigerator, which contained undated and uncovered food items, as well as expired products like chocolate milk, salsa, and bologna. The Food Service Director noted that medications should not be stored in the refrigerator and that the dietary aid was responsible for monthly cleaning.
The facility failed to offer pneumonia vaccines to five eligible residents with various medical conditions, including Parkinson's disease and diabetes. Despite being eligible, these residents were not offered the vaccine, and the DNS could not provide documentation to confirm that the vaccine had been offered, placing them at risk for pneumonia.
The facility did not provide required dementia training for five CNAs within the last 12 months, as confirmed by the administrator. This deficiency was identified through interviews and record reviews, indicating a risk to residents with dementia who may not receive appropriate care.
The facility failed to uphold resident dignity and rights for two residents. One resident experienced leaking incontinence briefs, which were not addressed in their care plan despite staff awareness. Another resident was distressed after their roommate passed away and the body remained in their shared room for hours, with no offer to relocate. Both residents were cognitively intact, and the facility's inaction led to deficiencies in care.
A facility failed to ensure informed consent was obtained for psychotropic medications for a resident admitted with depression and later to hospice services. The resident was prescribed Abilify, Cymbalta, and lorazepam without evidence of consent forms in the clinical record. Facility staff indicated that consents should have been obtained prior to administration, but the hospice director noted that specific education on medication risks and benefits was not provided unless requested by the facility.
A resident with heart failure and a BIMS score of 15 repeatedly complained about long call light times, unclean room conditions, and rude staff. Despite assurances from the Social Services Director that these issues would be reported, there was no documented follow-up or resolution. Interviews revealed that the concerns were only reported to nursing, and the LPN Resident Care Manager merely reassured the resident without addressing the grievances. The facility's grievance process was not followed, and the resident confirmed that the issues remained unresolved.
The facility failed to provide bowel care and follow medication orders for three residents. A resident with dementia did not receive bowel care despite not having a bowel movement for five days, and another resident with depression experienced similar issues without PRN medications or assessments. Additionally, a resident with heart failure received Lasix despite blood pressure readings below the physician-ordered threshold. These actions were not documented, placing residents at risk.
A resident with a history of seizures and heart disease was found smoking in a nonsmoking area without supervision, keeping a lighter in their coat pocket, contrary to the facility's smoking policy. Staff interviews revealed lapses in policy enforcement, including the absence of a check-out sheet for smoking paraphernalia.
A facility failed to provide adequate dialysis care for a resident with kidney failure. The care plan lacked instructions to avoid taking blood pressure on the arm with dialysis access and did not include emergency instructions for complications. Staff only assessed the dialysis site on dialysis days, and there was no sign indicating which arm to avoid for blood pressure measurements. The DNS confirmed these deficiencies, placing the resident at risk for complications.
A resident with PTSD did not receive trauma-informed care after a triggering incident due to the lack of a care plan. Despite being diagnosed with PTSD, the resident's condition was not addressed in their care plan until months after admission, following an incident that exacerbated their symptoms. Staff interviews revealed that the care plan should have been initiated earlier, highlighting a deficiency in the facility's care approach.
The facility did not complete annual performance reviews for two CNAs, which could risk resident care quality due to potentially incompetent staff.
A facility failed to provide a rationale for PRN psychotropic medication and did not develop a care plan for a resident on lorazepam for restlessness. The care plan lacked details on psychotropic medication use, side effects, and nonpharmacological interventions. Staff acknowledged the absence of necessary documentation, placing the resident at risk for sedation.
A resident admitted with a stroke diagnosis did not receive the required therapy evaluation and services as per hospital orders. Despite the physician's note indicating the need for skilled PT, OT, and SLP, the resident's record showed no therapy services were provided. Staff interviews confirmed that the therapy services were missed, and there was no follow-up with the provider to ensure the resident received the necessary therapy.
A resident with quadriplegia signed a binding arbitration agreement without understanding its implications, as the Social Services Director did not explain the agreement. The resident later expressed they would not have signed if they had known it meant waiving the right to sue the facility.
The facility failed to offer COVID-19 vaccines to three eligible residents, including one with Parkinson's disease, another with a stroke, and a third with seizures. The DNS confirmed their eligibility but could not provide documentation that the vaccine was offered.
A resident with PTSD was physically assaulted by another resident in the dining room after a disagreement over phone volume. The facility's investigation confirmed the abuse, noting that the aggressor had no prior history of physical aggression. Staff separated the residents and assessed them for injuries, with none noted.
A facility failed to maintain respiratory equipment for a resident with congestive heart failure. The resident, who was cognitively intact, had an order for PRN oxygen but no instructions for cleaning the oxygen concentrator. The resident reported the concentrator was filthy and had not been cleaned recently. Facility policy required weekly cleaning, but there was no documentation of this being done, and staff confirmed it should have been cleaned weekly.
The facility failed to arrange mental health services for two residents with mental health diagnoses after a resident-to-resident incident. Despite the need for follow-up, neither resident was seen by a mental health provider, as the facility lacked a visiting mental health professional.
A facility failed to act on a pharmacist's recommendation for a gradual dose reduction of psychotropic medications for a resident with depression, schizoaffective disorder, and anxiety. Despite a signed order for a psychiatric consult, there was no evidence that the consult occurred. Staff acknowledged the failure to follow up timely on the recommendation.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by several deficiencies observed during the survey. Resident 6's bathroom light was dim, making it difficult and unsafe for the resident to navigate the bathroom. This issue was acknowledged by both the CNA and the Maintenance Director, who confirmed the light had been dim for at least a week. Resident 13 reported damaged walls in their room due to the bed scraping against them, which had not been repaired despite multiple requests to maintenance. The Maintenance Director admitted difficulty in completing repairs due to room occupancy, and the Administrator acknowledged that walls in disrepair did not contribute to a homelike environment. Resident 22 experienced a cracked bathroom window and cold water in their sink, with the water temperature recorded at 59 degrees Fahrenheit. The Administrator confirmed that the cracked window and cold water were identified but not addressed, and the Maintenance Director noted a pump issue preventing hot water from reaching the resident's room. Resident 26 faced a malfunctioning bed that was stuck in a high position, preventing them from safely getting in and out of bed. Despite being aware of the issue, the bed remained broken for several days, causing significant discomfort and mobility issues for the resident. These deficiencies collectively contributed to an environment that was not conducive to the residents' safety and comfort.
Unsanitary Food Storage in Resident's Refrigerator
Penalty
Summary
The facility failed to store food in a sanitary manner in a resident's room refrigerator, as observed during a survey. The refrigerator contained several undated and uncovered food items, including a plate of meatballs, a bowl of pears, and a dessert. Additionally, there were expired items such as chocolate milk, salsa, hot dogs, cole slaw, and bologna, with some items dating back to January. A container of cottage cheese was dated 2/12/25, and a sandwich was dated 2/21/25, both of which were past the facility's stated policy of discarding items three days after the date provided by the kitchen. Furthermore, a green canister with an unknown powder and an undated pitcher labeled as bowel prep with a resident's name were also found in the refrigerator. Staff 12, the Food Service Director, acknowledged that medications should not be stored in the refrigerator and that the dietary aid was responsible for cleaning it monthly.
Failure to Offer Pneumonia Vaccines to Eligible Residents
Penalty
Summary
The facility failed to ensure that residents were offered pneumonia vaccines, as evidenced by the review of clinical records and interviews with staff. Five residents, each with different medical conditions such as Parkinson's disease, diabetes, kidney failure, stroke, and seizures, were identified as eligible for the pneumonia vaccine but were not offered it. This oversight was confirmed by Staff 2, the Director of Nursing Services (DNS), who was unable to provide documentation that the vaccine had been offered to these residents. The deficiency was identified during a survey conducted on February 27, 2025, when Staff 2 verified the eligibility of the residents for the pneumonia vaccine. Despite requests for documentation to confirm that the vaccine had been offered, no additional information was provided. This lack of documentation and failure to offer the vaccine placed the residents at risk for pneumonia, as they were not given the opportunity to receive the preventive measure they were eligible for.
Failure to Provide Dementia Training for CNAs
Penalty
Summary
The facility failed to provide required dementia training for five Certified Nursing Assistants (CNAs), identified as Staff 4, 9, 21, 22, and 23, within the last 12 months. This deficiency was identified through interviews and record reviews, which revealed that the in-service records did not show completion of dementia training for these staff members. The lack of training placed residents with dementia at risk of not receiving appropriate care and services necessary to attain or maintain their highest practicable level of well-being. The facility's administrator confirmed the deficiency during an interview.
Failure to Uphold Resident Dignity and Rights
Penalty
Summary
The facility failed to uphold resident rights and dignity for two residents, leading to deficiencies in care. Resident 13, who was cognitively intact with a BIMS score of 15, experienced issues with leaking incontinence briefs. Despite raising concerns during a Resident Council meeting, no changes were made to the care plan to address the issue. Observations confirmed that Resident 13 often had a wet peri area and a strong smell of urine, which discouraged participation in activities due to embarrassment. Staff members were aware of the leaking briefs but failed to communicate this to the care planning team, resulting in a lack of appropriate intervention. Resident 26, also cognitively intact with a BIMS score of 15, was distressed after their roommate, Resident 100, passed away and the body remained in their shared room for several hours. There was no documentation indicating that staff offered to move Resident 26 or the deceased resident's body to another location. The Social Services Director acknowledged the incident and expressed that Resident 26 should have been alerted and possibly moved. The LPN Resident Care Manager confirmed that no actions were taken to relocate Resident 26 or provide additional support following the death of their roommate.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident or the resident's representative was provided with information regarding the risks and benefits of psychotropic medications before administration. This deficiency was identified for a resident who was admitted to the facility in June 2022 with a diagnosis of depression and later admitted to hospice services in January 2025. The resident was prescribed Abilify, Cymbalta, and lorazepam, but there was no evidence of consent forms for these medications in the resident's clinical record. Interviews with facility staff revealed that consents for psychotropic medications should have been obtained prior to administration. The hospice director stated that while general admission consent and treatment plans were reviewed upon admission to hospice services, the risks and benefits of psychotropic medications were not discussed unless the facility provided a specific form and requested the inclusion of this education in the admission process.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to adequately address grievances raised by a resident, identified as Resident 26, who was admitted with a diagnosis of heart failure and was cognitively intact with a BIMS score of 15. Over a period from May 14, 2024, to June 3, 2024, Resident 26 repeatedly complained to the Social Services Director, identified as Staff 7, about long call light response times, unclean room conditions, food issues, and rude staff. Despite assurances from Staff 7 that these concerns would be reported to the appropriate departments, there was no documented follow-up or resolution of these grievances in the resident's medical record or the facility's grievance binder. Interviews conducted on February 28, 2025, revealed that Staff 7 only reported the concerns to nursing and took no further action. The LPN Resident Care Manager, identified as Staff 3, stated that she merely had conversations with Resident 26, encouraging them that there was no staffing problem, without addressing the specific grievances. The Regional Nurse Consultant and the Director of Nursing Services, identified as Staff 29 and Staff 2 respectively, acknowledged the lack of adherence to the grievance process and were unaware of the resident's documented concerns. Resident 26 confirmed that the facility did not resolve the issues and had not communicated any follow-up actions regarding the grievances.
Failure to Provide Bowel Care and Follow Medication Orders
Penalty
Summary
The facility failed to provide appropriate bowel care and follow physician orders for medication parameters for three residents. Resident 9, diagnosed with dementia, did not have a bowel movement for five days, and there was no documented nursing assessment or rationale for not providing bowel care. Staff confirmed that bowel care should be initiated if a resident does not have a bowel movement for three days, but this protocol was not followed. Similarly, Resident 22, with a diagnosis of depression, experienced two instances of not having a bowel movement for four days without any PRN bowel care medications ordered or nursing assessments documented. Staff acknowledged that bowel care should have been administered, but it was not, and there was a lack of documentation regarding the resident's bowel movements. Resident 24, diagnosed with heart failure, had a physician order to hold Lasix if the systolic blood pressure was less than 110. Despite this, the medication was administered on multiple occasions when the resident's blood pressure was below the specified threshold. Staff confirmed that the medication should have been held on those days, but there was no evidence in the progress notes that this was done. These failures in following physician orders and documenting care placed the residents at risk for adverse health outcomes.
Failure to Enforce Smoking Policy and Supervision
Penalty
Summary
The facility failed to ensure that cigarette lighters were not stored in resident rooms, specifically for one resident who was reviewed for smoking. This resident, admitted in October 2022 with diagnoses of seizures and heart disease, was identified as a supervised smoker due to noncompliance with the facility's smoking policy. The policy stated that smoking was only permitted in designated areas and that all cigarettes and lighters were to be kept locked at the nurse's station. However, during an observation, the resident was found smoking in a nonsmoking area without staff supervision and admitted to keeping a lighter in a box in their coat pocket. Interviews with various staff members revealed inconsistencies in the enforcement of the smoking policy. The Activities Director and a CNA confirmed that residents were supposed to check out their smoking paraphernalia from the nurse's station. However, an LPN noted that the check-out sheet used to track cigarettes and lighters was no longer in use, making it difficult to monitor compliance. The DNS and LPN resident care manager confirmed that the resident was a supervised smoker due to noncompliance and should not have had smoking paraphernalia in their room.
Failure to Provide Adequate Dialysis Care
Penalty
Summary
The facility failed to provide adequate care and services related to dialysis for a resident diagnosed with kidney failure. The resident, who was cognitively intact, was admitted to the facility with a care plan that included scheduled dialysis sessions on Mondays, Wednesdays, and Fridays. However, the care plan lacked specific instructions for staff to avoid taking blood pressure on the arm with the dialysis access and did not include emergency instructions for complications such as bleeding. The facility's policy required documentation of the dialysis site condition every shift, but staff only assessed and documented the site on dialysis days. Observations and interviews revealed that staff were not consistently following the facility's Dialysis Access and Care Policy. A Licensed Practical Nurse (LPN) assessed the dialysis site only on dialysis days, and a Certified Nursing Assistant (CNA) noted the absence of a sign in the resident's room indicating which arm should not be used for blood pressure measurements. The Director of Nursing Services (DNS) confirmed the care plan's deficiencies, acknowledging the lack of instructions for blood pressure monitoring and emergency care for the dialysis site. This oversight placed the resident at risk for dialysis access complications.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care to a resident diagnosed with post-traumatic stress disorder (PTSD). The resident, who was admitted in July 2022, experienced a triggering event when another male resident made an inappropriate comment, which exacerbated the resident's PTSD symptoms. Despite being cognitively intact and having a PTSD diagnosis, the resident did not have a care plan addressing PTSD until February 26, 2025, following the incident. This lack of a care plan left the resident without necessary support for managing PTSD triggers. Interviews with facility staff revealed that a PTSD care plan should have been initiated upon the resident's admission or upon receiving the PTSD diagnosis in November 2024. The Social Services Director admitted to not having completed a trauma/PTSD assessment for the resident upon admission, as she was not employed at the facility at that time. The facility's administrator stated that the resident's PTSD was not care planned because the resident did not request it, and the facility aimed to avoid prying. This oversight resulted in the resident's PTSD not being adequately addressed, leading to a deficiency in providing trauma-informed care.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to ensure that each Certified Nursing Assistant (CNA) received annual performance reviews, specifically for two of the five sampled CNAs. This deficiency was identified during an interview and record review, where it was confirmed that the annual performance reviews for Staff 21 and Staff 23 had not been completed within the last 12 months. The absence of these reviews placed residents at risk for receiving care from potentially incompetent staff.
Failure to Provide Rationale and Care Plan for PRN Psychotropic Medication
Penalty
Summary
The facility failed to provide a rationale for the use of PRN psychotropic medication and did not develop a care plan addressing the side effects of antianxiety medication for a resident diagnosed with depression. The resident was admitted to hospice services with orders for lorazepam to be administered PRN for restlessness. However, the care plan did not include details on the use of psychotropic medication, potential side effects of lorazepam, or nonpharmacological interventions to be attempted prior to administering the medication. The facility's staff, including an LPN and the Director of Nursing Services (DNS), acknowledged the absence of a rationale for the continuation of lorazepam and the lack of documentation of nonpharmacological interventions. The DNS confirmed that lorazepam is not an antipsychotic medication and verified the absence of a psychotropic care plan. This oversight placed the resident at risk for sedation due to the lack of a comprehensive care plan and appropriate documentation.
Failure to Provide Required Therapy Evaluation
Penalty
Summary
The facility failed to ensure a therapy evaluation was obtained for a resident who was admitted with a diagnosis of a stroke. The resident was admitted to the facility with hospital orders indicating the need for skilled therapy services, including physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP). However, the resident's record showed no therapy services were provided. Interviews with staff revealed that the therapy services were overlooked, and there was no follow-up with the resident's provider to confirm the need for therapy services. This oversight was acknowledged by the staff, who admitted that the therapy services were missed.
Failure to Inform Resident About Binding Arbitration Agreement
Penalty
Summary
The facility failed to ensure that residents were fully informed and understood the binding arbitration agreement, as evidenced by the case of a resident with quadriplegia who was admitted in November 2022. On September 20, 2023, the resident signed an Arbitration Agreement with the new owner of the facility. However, during an interview on February 27, 2025, the resident stated they did not know what a binding arbitration agreement was and would not have signed it if they had known it meant giving up the right to sue the facility in court. Interviews with the Social Services Director revealed that the form was left with the resident at their request, and the director was unaware of the requirement to explain the binding arbitration agreement to residents.
Failure to Offer COVID-19 Vaccines to Eligible Residents
Penalty
Summary
The facility failed to offer COVID-19 vaccines to three eligible residents, placing them at risk for respiratory illness. Resident 19, admitted in September 2022 with Parkinson's disease, was eligible but not offered the vaccine. Similarly, Resident 38, admitted in August 2024 with a stroke diagnosis, and Resident 39, admitted in September 2024 with seizures, were also eligible but not offered the vaccine. Staff 2, the Director of Nursing Services (DNS), confirmed the eligibility of these residents for the vaccine but could not provide documentation that the vaccine was offered to them.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident. Resident 39, who was admitted with a diagnosis of post-traumatic stress disorder (PTSD), reported being hit on the head several times by Resident 20, who also had a diagnosis of PTSD. The incident occurred in the dining room when Resident 20 asked Resident 39 to lower the volume on their phone. Despite Resident 39's claim of compliance, Resident 20 proceeded to physically assault Resident 39. The facility's investigation confirmed the abuse, noting that Resident 20 had no prior history of physical aggression, although they were known to react verbally to loud noises. Staff interviews corroborated the sequence of events, with staff members stating that Resident 39 reported the incident immediately, and both residents were separated and assessed for injuries, with none noted. The police were notified, and Resident 39 pressed charges against Resident 20.
Failure to Maintain Respiratory Equipment
Penalty
Summary
The facility failed to maintain respiratory equipment for a resident with a diagnosis of congestive heart failure, who was cognitively intact as per a recent MDS assessment. The resident had an order for PRN oxygen, but there were no instructions for cleaning the oxygen concentrator. The resident reported that the concentrator had not been cleaned recently and was filthy. The facility's policy required oxygen cannula and tubing to be changed every seven days and filters to be washed weekly. However, there was no documentation of the concentrator being cleaned, and staff confirmed that it should have been cleaned weekly, including for residents on PRN oxygen.
Failure to Arrange Mental Health Services for Residents
Penalty
Summary
The facility failed to provide medically-related social services by not arranging mental health services for two residents with significant mental health diagnoses. Resident 20, who was admitted with schizoaffective disorder, bipolar disorder, post-traumatic stress disorder, and borderline personality disorder, was involved in an incident where he hit another resident on the head. Despite the facility's investigation indicating a need for mental health follow-up, there was no evidence that Resident 20 was seen by a mental health provider after the incident. Similarly, Resident 39, who was admitted with bipolar disorder and post-traumatic stress disorder, was the victim in the same incident. The facility's investigation also noted the need for mental health follow-up for Resident 39, but a review of the medical records showed no evidence of such follow-up. The facility acknowledged the lack of mental health services for both residents, as they did not have a mental health provider visiting the facility at the time.
Failure to Act on Pharmacist Recommendations for Psychotropic Medications
Penalty
Summary
The facility failed to act upon pharmacist recommendations for a resident reviewed for unnecessary medications, which placed residents at risk for a decrease in their quality of life. The resident was admitted with diagnoses including depression, schizoaffective disorder, and anxiety. Physician orders included aripiprazole for schizoaffective disorder, duloxetine for depression, and depakote for schizoaffective disorder. A pharmacist recommended a gradual dose reduction (GDR) for the resident's psychotropic medications, and the recommendation was signed by the provider with an order for a psychiatric consult to discuss the GDR. However, there was no evidence in the medical record that the pharmacist's recommendation for a psychiatric consult was acted upon. Staff acknowledged that the facility did not follow up timely for the psychiatric consult, which should have been done within one week of receiving the order.
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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