Robison Jewish Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Portland, Oregon.
- Location
- 6125 Sw Boundary Street, Portland, Oregon 97221
- CMS Provider Number
- 385145
- Inspections on file
- 23
- Latest survey
- November 4, 2025
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Robison Jewish Health Center during CMS and state inspections, most recent first.
A resident was admitted with a documented Stage 2 pressure ulcer on the penis, but facility staff failed to identify, assess, treat, or monitor the wound as required. Despite multiple staff observing signs of injury and the resident expressing discomfort, there was no documentation or care planning for the ulcer. The condition worsened, resulting in severe tissue erosion and permanent loss of normal urinary function, as confirmed during a subsequent hospital stay.
The facility did not monitor for legionella in its water system as required by its infection control policy. Maintenance staff had not been trained or instructed to check for water borne pathogens, and the Maintenance Director was unaware of at-risk areas and confirmed no monitoring had occurred. An LPN-Infection Preventionist also had not been involved in identifying or monitoring areas at risk for legionella.
The facility did not have an effective system for receiving, tracking, or resolving grievances, as shown by missing and incomplete records, staff confusion about the grievance process, and residents' lack of understanding about how to file grievances. A resident with cancer and diabetes was unable to submit a grievance about a delayed transportation incident due to staff not providing the necessary form or follow-up. The administrator acknowledged the absence of a clear grievance tracking system, resulting in unresolved resident concerns.
Staff failed to keep medication and treatment carts locked and attended, leaving medications, including insulin and prescribed drugs for a resident with Parkinsonism and hypothyroidism, accessible to unauthorized personnel. Multiple carts were observed unlocked in different areas, and staff acknowledged the lapses in following medication security protocols.
Three residents with orders for PT and OT did not receive the frequency of therapy sessions prescribed by their physicians. One resident with chronic venous ulcers received no PT after an initial refusal, another with hemiplegia received only one PT session despite orders for twice-weekly therapy, and a third with lymphoma and diabetes received fewer PT and OT sessions than ordered. Staff and the administrator confirmed that insufficient therapy staffing led to the failure to provide services as ordered.
The facility did not consistently follow physician orders for medication administration and failed to assess and treat a change in a resident's skin condition. One resident received cancer medication late on multiple occasions, another missed and received late doses of antiseizure medication, and a third experienced ongoing itching and skin damage without proper assessment or physician notification. Staff interviews and documentation confirmed these deficiencies.
Two residents experienced deficiencies in their environment: one had personal belongings go missing after admission, with multiple staff failing to recover or replace the items, and another suffered significant sleep loss due to a neighbor's loud television, despite repeated complaints to staff. Staff interviews revealed a lack of training and ineffective interventions, resulting in unresolved issues with both property loss and excessive noise.
A resident with a hip fracture received PRN lorazepam for agitation and anxiety over several months, with administration records showing repeated use beyond the facility's 14-day policy limit. Staff confirmed that a physician did not re-evaluate or document a rationale for extending the PRN order as required.
The facility did not notify the state Long Term Care Ombudsman’s office when two residents—one with post-surgical cellulitis and another with Alzheimer’s and metabolic encephalopathy—were transferred to the hospital and subsequently discharged. Record reviews and staff interviews confirmed that required notifications were not made, and key staff were unaware of this requirement.
A resident with hemiplegia and finger contractures did not receive prescribed contracture management interventions, such as a contracture pillow or rolled washcloth, as ordered in the care plan. Staff interviews and observations revealed that these interventions were frequently missed, and no ongoing monitoring or range of motion (RA) exercises were documented or provided. Staff were unclear about their responsibilities, and the designated RA provider was unavailable, resulting in a lack of consistent care for the resident's contractures.
A resident requiring maximum assistance and use of a Hoyer lift for bathing did not receive scheduled showers on multiple occasions due to lack of staff and equipment availability. Staff and a family member confirmed that bathing was not provided as care planned, and documentation reflected missed showers without make-up baths.
Two residents identified as high fall risks did not receive or have documented neurological checks following falls, as required by facility protocol. Despite experiencing pain and being assessed by LPNs, there was no evidence in the clinical records that neuro checks were completed for either resident. Staff interviews and record reviews confirmed the lack of documentation and adherence to post-fall procedures.
A resident with cognitive impairment and left-sided weakness did not receive care in a dignified manner as per their care plan. A CNA was observed on video providing peri-care without proper cues, causing the resident to express pain. The CNA admitted the care was not performed according to the care plan, and the facility confirmed the lack of dignified care.
A resident with dementia and severe cognitive impairment, known for wandering and exit-seeking, fell and sustained serious injuries after exiting through an unarmed door alarm. The facility failed to implement necessary interventions or update the care plan despite the resident's increased wandering behavior.
The facility failed to maintain sanitary conditions for the ice machine, risking foodborne illness for residents. A powdery gray/green substance was found on the ice machine panel, with condensation dripping onto the ice. The Executive Chef acknowledged the issue, noting the machine was cleaned monthly but not included in weekly or daily cleaning schedules.
The facility failed to implement infection control practices for residents with catheters and those receiving wound care, as staff did not use gowns during high-contact care activities. Additionally, an LPN was observed administering medication without performing hand hygiene or using proper techniques, contrary to facility policy.
The facility failed to provide sufficient nursing staff to meet resident needs, leading to delays in care and increased safety risks. Staff and residents reported frequent understaffing, particularly on night shifts, resulting in unmet care needs and residents being left unattended. Despite reporting these issues, no changes were made to address the staffing deficiencies.
The facility failed to secure medication carts and manage expired drugs, as observed with unlocked and unattended carts and expired medications like Lantus insulin and influenza vaccines. Staff confirmed these lapses, and the DNS expected all carts and refrigerators to be locked and free of expired medications.
The facility failed to implement person-centered care plans for two residents, leading to deficiencies in fall prevention and medication management. One resident, at moderate fall risk, had a care plan intervention to keep the bed low, but it was not followed. Another resident on Apixaban, a high-risk medication, lacked proper monitoring in their care plan.
A resident with paroxysmal atrial fibrillation and other conditions was prescribed apixaban twice daily, but the facility failed to ensure consistent administration due to the resident's pattern of evening refusals. Despite extending the administration window, the refusals continued, and no further interventions were implemented, risking medical complications.
A resident with atrial fibrillation was not seen by a physician as required after admission, despite facility policy mandating visits every 30 days for the first 90 days and every 60 days thereafter. Staff confirmed the lack of documented physician visits since the resident's admission.
Two residents with moderately impaired cognition received expired COVID-19 vaccines due to an RN being distracted and failing to check expiration dates. The DNS expected expired vaccines to be disposed of promptly. Both residents were monitored for adverse side effects.
Failure to Identify, Assess, and Treat Stage 2 Penile Pressure Ulcer on Admission
Penalty
Summary
A resident was admitted to the facility with a documented Stage 2 pressure ulcer located on the left lateral meatus of the penis, as indicated in the admission and discharge paperwork from the previous facility. The documentation included specific orders to apply triple antibiotic ointment every shift with catheter care and to consult the Resident Care Manager if the wound worsened. However, upon admission, the facility failed to identify, assess, treat, or monitor the pressure ulcer. The resident's initial skin assessment, care plan, physician orders, and subsequent clinical records did not mention the presence of the pressure ulcer or any related treatment. Throughout the resident's stay, there was no documentation in the medical record or treatment administration records regarding the penile pressure ulcer. Multiple staff members, including CNAs and nurses, observed signs of injury such as bleeding, a tear, or a split on the penis during perineal or catheter care, but these observations were either not documented or not followed up with appropriate assessment and intervention. The resident also reported discomfort and requested to see a urologist, but there was no evidence that these concerns were addressed. Progress notes and care plans continued to omit any reference to the pressure ulcer or its management. The resident was eventually hospitalized, where it was discovered that the Foley catheter had caused significant erosion of the penile tissue, resulting in traumatic hypospadias and permanent loss of normal urinary function. Hospital records and interviews with hospital staff confirmed that the injury was consistent with prolonged catheter-related pressure and not an acute event. Facility leadership and care management staff were unaware of the pressure ulcer at the time of the survey, despite its documentation at the prior facility and multiple staff observations during the resident's stay.
Failure to Monitor for Legionella in Facility Water System
Penalty
Summary
The facility failed to monitor for legionella in its water system, as required by its Infection Prevention and Control Program policy. The policy indicated that a water management program was established, with control measures and testing protocols in place, and designated the Maintenance Director as the leader of the program. However, interviews revealed that maintenance technicians had not received training on water borne pathogens and were not instructed to monitor for legionella. The Maintenance Director was unaware of areas at risk for legionella development and confirmed that no monitoring had been performed for legionella or other water borne pathogens. Additionally, the LPN-Resident Care Manager/Infection Preventionist acknowledged understanding that legionella could develop in areas of standing water but had not participated in identifying at-risk areas or monitoring for legionella. No specific residents or their medical conditions were mentioned in the report.
Failure to Maintain Effective Grievance System and Staff Training
Penalty
Summary
The facility failed to maintain an effective system for receiving, tracking, and resolving resident and/or representative grievances, as required by its own grievance policy. Review of the facility's grievance binder revealed missing records for several months and incomplete documentation for others. During a Resident Council meeting, residents expressed confusion about how to file grievances and reported a lack of follow-up on submitted concerns. Staff interviews confirmed a lack of training and understanding regarding the grievance process, with some staff unaware of the location or purpose of grievance forms and others believing it was not their responsibility to assist residents with grievances. The Social Services staff acknowledged the absence of a consistent protocol for processing grievances and a tracking system to monitor resolution. One resident, admitted with diffuse large B-cell lymphoma and type 2 diabetes, experienced a significant delay in transportation after a medical appointment. The resident attempted to file a grievance regarding the 20-hour wait but did not receive the necessary form or follow-up from staff. The nurse involved admitted to not providing the grievance form and was unaware of its location. Other staff members also demonstrated confusion about the grievance process and the availability of forms, with some believing the forms were intended for employees rather than residents. The facility administrator confirmed that there was no clear system in place for tracking grievances or ensuring that concerns were addressed and resolved. The lack of a functioning grievance procedure and inadequate staff training placed residents at risk for unreported and unresolved grievances, as evidenced by incomplete records, staff confusion, and resident reports of unresolved issues.
Failure to Secure Medications and Treatment Carts
Penalty
Summary
Facility staff failed to ensure that medications and biologicals were consistently secured and only accessible to authorized personnel, as required by facility policy. On multiple occasions, medication and treatment carts were observed unlocked and unattended in various areas, including the 300 Household, 700 Hall, and 900 Household. In one instance, a cup containing crushed medications mixed with a pudding-like substance, prepared for a resident with Parkinsonism and hypothyroidism, was left unattended on top of a medication cart. The nurse responsible for the cart was not present, and the cup was accessible to unauthorized staff. Staff later acknowledged that the medications should have been locked in the cart when unattended. Additionally, treatment carts containing insulin and medicated creams were found unlocked and unattended in both the 700 Hall and 300 Household. Staff admitted to leaving carts unlocked due to a lack of keys when agency staff were present. In another area, a medication cart was left unlocked, allowing staff to access its contents and use items from the cart without supervision. Facility leadership confirmed that all medications and carts should have been secured when not directly attended by authorized staff.
Failure to Provide Ordered Rehabilitation Services Due to Staffing Shortages
Penalty
Summary
The facility failed to provide occupational and physical therapy services as ordered for three of four sampled residents who required specialized rehabilitative services. According to the facility's own policy, such services are to be provided under physician orders by qualified personnel and are considered part of the facility's scope of services. However, documentation and staff interviews confirmed that residents did not receive the therapy sessions as prescribed. One resident with chronic venous hypertension and ulcers was evaluated for physical therapy four to five times per week but did not receive any sessions beyond an initial refusal, with no further attempts documented. Another resident with hemiplegia following a stroke was evaluated and ordered to receive physical therapy twice weekly but only received one session, with no explanation for the lack of further therapy. A third resident with diffuse large B-cell lymphoma and diabetes, who required assistance with mobility and was at risk for falls, was ordered to receive both physical and occupational therapy three to five times per week but only received two sessions of each per week, less than what was ordered. Staff interviews revealed that the primary reason for the missed therapy sessions was insufficient therapy staffing, which prevented the facility from meeting the frequency of therapy sessions indicated in the residents' evaluations and physician orders. The Director of Rehabilitation, who was responsible for scheduling, worked offsite and confirmed the lack of adequate staff to provide the required services. The facility administrator acknowledged the issue, stating that the census of residents needing therapy exceeded the available therapy staff.
Failure to Follow Physician Orders and Address Changes in Resident Condition
Penalty
Summary
The facility failed to follow physician orders and did not provide appropriate assessment and treatment for changes in residents' conditions, as evidenced by three separate cases. One resident with multiple myeloma was prescribed Venetoclax to be administered at specific times and in a specific manner, but the medication was given late on at least twenty-seven occasions. Staff acknowledged the delays, citing the resident's difficulty swallowing and the time required for administration, and stated that the medication was often given at the end of the medication pass. The resident and family members expressed concerns about the timeliness of medication administration, and staff confirmed that the medication was not consistently given within the required timeframe. Another resident with epilepsy and hemiplegia was prescribed Lacosamide to be administered twice daily at set times. Upon admission, the resident missed the first scheduled dose due to a script not being sent with the resident, and subsequent doses were administered late on multiple occasions. Staff interviews confirmed that antiseizure medications were expected to be prioritized and administered within a specific window, but this was not consistently achieved for this resident. A third resident with Parkinsonism reported persistent itching and suspected an allergic reaction to bedding, which resulted in frequent scratching and visible skin damage. The resident reported the issue to multiple CNAs, but the concern was not escalated to nursing staff or the physician. Observations confirmed the presence of scratch marks and bleeding, and staff interviews revealed that while some applied lotion, no further assessment or intervention was initiated, and the physician was not notified of the ongoing skin condition.
Failure to Protect Resident Property and Ensure Comfortable Sound Levels
Penalty
Summary
The facility failed to maintain a homelike environment by not exercising reasonable care for the protection of residents' personal property and by not ensuring comfortable sound levels for residents. One resident, admitted with Parkinsonism and cognitively intact, reported missing personal items such as dress shirts and pants shortly after admission. The resident and a family member stated that the missing items were reported to multiple staff members, but no action was taken to recover or replace the items. Interviews with CNAs revealed a lack of training on handling missing property, and the Housekeeping/Laundry Supervisor acknowledged frequent mix-ups of resident belongings due to high staff turnover and agency staff usage. The Administrator stated that missing items should be reported and replaced within seven days, but was unaware of the specific case involving this resident. Another resident, admitted with gram-negative sepsis and anxiety disorder and with moderate cognitive impairment, experienced significant sleep disruption due to excessive noise from a neighboring resident's television. The neighbor, who also had moderate cognitive impairment and preferred watching television, played the television at a volume that was clearly audible in the affected resident's room, even with doors closed. The affected resident reported only sleeping about three hours per night and expressed distress over the situation. Multiple staff and a private caregiver confirmed ongoing complaints about the noise, and staff interventions such as providing headphones were only temporarily effective, as the neighbor eventually stopped using them and continued to play the television loudly. Staff interviews indicated that complaints about the noise were reported to CNAs and, in some cases, to nurses, but the issue persisted. The Administrator acknowledged awareness of the situation and stated that headphones had been provided, but was not fully aware of the extent of the problem at night. The facility's failure to address these issues resulted in a lack of a homelike environment, lost sleep, and unaddressed loss of personal property for the residents involved.
Failure to Re-Evaluate PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications, specifically regarding the use of PRN lorazepam. According to the facility's policy, PRN orders for psychotropic medications, excluding antipsychotics, must be limited to 14 days unless the attending physician or prescribing practitioner provides documentation with a rationale for extending the order and specifies a duration. A resident who was readmitted with a hip fracture had a physician order for lorazepam every four hours PRN for agitation and anxiety. Review of the resident's medication administration records showed that lorazepam was administered multiple times over several months, exceeding the 14-day limit without any documented physician rationale or re-evaluation for the continued use of the medication. During interviews, staff confirmed that the required physician re-evaluation did not occur at the end of the 14-day period, and acknowledged that this step should have been completed.
Failure to Notify LTCO of Resident Transfers and Discharges
Penalty
Summary
The facility failed to notify the state Long Term Care Ombudsman’s (LTCO) office regarding the transfer or discharge of two residents who were hospitalized and subsequently discharged. For one resident admitted with aftercare following surgery and cellulitis, documentation showed a transfer to the hospital for nausea and vomiting, but there was no record of LTCO notification. For another resident with Alzheimer’s Disease and metabolic encephalopathy, records indicated a hospital transfer due to wound complications and subsequent discharge from the facility, again without any evidence of LTCO notification. Interviews with facility staff, including the Director of Nursing Services (DNS) and the Administrator, revealed that both were unaware of the requirement to notify the LTCO’s office for resident transfers and discharges. The lack of notification was confirmed through both record review and staff statements, indicating a systemic failure to ensure required notifications were made for residents experiencing significant changes in their care setting.
Failure to Provide Contracture Management and Range of Motion Services
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent further decreases in range of motion for a resident with hemiplegia and existing contractures in the fingers of one hand. The resident's care plan and physician orders specified the use of a contracture pillow or a rolled washcloth during the day to manage contractures, but observations over several days revealed that these interventions were not consistently implemented. The resident was repeatedly observed without the prescribed contracture pillow or rolled washcloth in place, and staff interviews confirmed that these items were often overlooked or not provided as ordered. Further, there was no evidence in the clinical record of comprehensive assessment, ongoing monitoring, or range of motion (RA) exercises being completed for the resident. Multiple staff members, including CNAs, LPNs, and therapy staff, indicated confusion or lack of knowledge regarding responsibility for implementing the contracture interventions. Some staff stated that RA services were not being provided, and others were unaware of the resident's needs or the existence of a contracture pillow. The designated staff member responsible for RA was on leave, and no alternative arrangements were made, resulting in a lack of consistent care to address the resident's contractures.
Failure to Provide Bathing Assistance as Care Planned
Penalty
Summary
A resident with a history of stroke, admitted in May 2025, was care planned to require maximum assistance with a Hoyer lift and was dependent on staff for showering twice weekly and as needed. Review of task charting for June, July, and August 2025 showed that on multiple occasions, bathing was documented as 'not applicable' by several CNAs, with no evidence that make-up showers were provided. Staff interviews confirmed that bathing was not completed on these dates due to lack of available staff to assist with the Hoyer lift or unavailability of the lift itself. A family member reported that the resident was not provided assistance with showers as required. Staff, including CNAs and an RN care manager, acknowledged that the resident was not bathed or showered on the documented dates, citing ongoing staffing difficulties. The administrator and director of nursing services confirmed that residents should be bathed according to their care plans and as needed.
Failure to Complete and Document Post-Fall Neurological Checks
Penalty
Summary
The facility failed to provide treatment and care according to professional standards of practice by not completing and documenting neurological checks (neuro checks) after falls for two residents identified as high fall risks. According to the facility's fall procedure, residents who experience a fall are to be placed on neuro checks for 72 hours, with each check documented in the Neuro Check Binder. For one resident with a history of joint replacement surgery and self-care deficits, an unwitnessed fall occurred while attempting to self-transfer. Although the resident reported back pain and received pain medication, there was no documentation that neuro checks were performed or recorded following the fall. A subsequent progress note indicated that the responsible LPN failed to complete the required neuro assessments. Another resident, admitted with a right femur fracture and dementia, also experienced a fall and was reportedly placed on neuro checks after complaining of significant pain. However, a review of the clinical record revealed no evidence that neuro check assessments were completed or documented. Staff interviews confirmed that neuro checks were not always performed due to time constraints, and the medical records staff verified the absence of documentation for both residents. The administrator and director of nursing services acknowledged that the post-fall neuro check procedures were not followed for these residents.
Failure to Provide Dignified Care
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident with cognitive impairment and left-sided weakness. The resident, admitted in October 2021, had a care plan that required non-rushed guided care and continuous face-to-face verbal communication during peri-care. However, a video recorded incident showed the CNA providing care in a manner that was not in accordance with the care plan. The CNA was observed grabbing the resident's groin without cues or prompting, causing the resident to respond verbally in a painful manner. The facility's investigation concluded that the resident did not show any adverse behaviors or injuries as a result of the incident. During a review of the video, the CNA was seen expressing frustration and grabbing the resident's genitals without proper cueing, which prompted the resident to yell in pain. The CNA denied providing inappropriate care but confirmed that the care was not performed according to the resident's care plan. The facility administrator confirmed that the care was not performed in a dignified manner as per the care plan.
Failure to Implement Fall Prevention Interventions for Wandering Resident
Penalty
Summary
The facility failed to implement necessary interventions to prevent a fall for a resident with a history of wandering and exit-seeking behavior. The resident, who was admitted with dementia and anxiety, was noted to have severe cognitive impairment and a pattern of wandering. Despite these known behaviors, the facility did not have exit-seeking or wandering interventions in place prior to the resident's fall. On the day of the incident, the resident exited the unit through a side door with unarmed alarms, resulting in a fall down the stairs with a walker. The fall led to serious injuries, including a head hematoma, gluteal hematoma, multiple rib fractures, and skin avulsions, requiring emergency medical services and hospitalization. Interviews with staff revealed that the door alarm was not reset by an unknown staff member, allowing the resident to exit unnoticed. Staff acknowledged the resident's increased wandering behavior prior to the fall, but no new interventions or updates to the care plan were implemented to address these changes.
Ice Machine Sanitation Deficiency
Penalty
Summary
The facility failed to ensure the ice machine was cleaned adequately to maintain sanitary conditions, which placed residents at risk of foodborne illness. During an observation, a powdery gray/green substance was found accumulated in the grooves of the panel directly above the ice supply in the kitchen's ice machine. Condensation was observed dripping across the panel's grooves and onto the ice supply. The Executive Chef/Director of Dining Services acknowledged the presence of the substance and confirmed that it should not be present and should be cleaned. A review of the Ice Machine Cleaning Log indicated that the machine was cleaned on a monthly basis, but the task was not included in the kitchen's weekly Deep Cleaning Schedule or Daily Cleaning Schedule. The Executive Chef/Director of Dining Services stated that the ice machine was expected to be cleaned to prevent contamination of the ice provided to residents.
Infection Control and Medication Administration Deficiencies
Penalty
Summary
The facility failed to implement proper infection control practices for 18 residents and one staff member, placing residents at risk for infection. Observations revealed that enhanced barrier precautions, such as the use of gowns and gloves during high-contact resident care activities, were not implemented for residents with urinary catheters or those receiving wound care. Despite the CDC guidelines specifying the need for such precautions, staff only wore gloves and not gowns during care. The facility's Infection Preventionist acknowledged that enhanced barrier precautions should have been in place for residents with catheters or those receiving wound care. Additionally, the facility's medication administration practices were found to be lacking in infection control measures. During a medication administration observation, an LPN was seen using her fingers to retrieve a pill and place it in a resident's mouth without performing hand hygiene before or after the task. The LPN admitted to not following the facility's policy, which requires hand hygiene before and after medication administration and prohibits touching medications with bare hands. The facility's DNS confirmed the expectation for hand hygiene and proper handling of medications.
Inadequate Staffing Leads to Unmet Resident Needs
Penalty
Summary
The facility failed to ensure sufficient nursing staff was available to meet the needs of its residents, as evidenced by multiple staff and resident reports. The facility had a census of 39 residents, with many requiring extensive assistance for daily activities such as transfers, bathing, toileting, and dressing. Staff interviews revealed that the facility often operated with inadequate staffing levels, particularly on the night shift, which led to residents waiting for assistance and increased risks of falls and elopement. Staff members reported that they were frequently unable to provide the necessary two-person assistance for transfers and care, leaving residents unattended and compromising their safety. The facility's staffing policy, revised in 2007, indicated that adequate staffing should be provided to meet residents' needs. However, staff members, including CNAs and LPNs, reported that the facility was often short-staffed, especially during the night shift. This shortage was exacerbated by the facility's decision to stop using agency staff and the lack of awareness of specific staffing requirements for bariatric residents. As a result, staff were unable to provide timely care, and residents experienced delays in having their needs met, such as waiting for call lights to be answered and for assistance with transfers and personal care. Residents and staff expressed concerns about the safety and supervision of residents, particularly in the 400 house, where residents with high acuity needs resided. Reports indicated that residents were left unattended, leading to incidents such as a resident wandering into another's room unsupervised. Staff were also burdened with additional non-care tasks due to staff reductions in other departments, further straining their ability to provide adequate care. Despite reporting these issues to the Director of Nursing Services and the Staffing Coordinator, no changes were made to address the staffing deficiencies.
Medication Security and Expiration Issues
Penalty
Summary
The facility failed to ensure the security and proper management of drugs and biologicals, as evidenced by several observations of unlocked and unattended medication carts and expired medications. On multiple occasions, medication carts on different halls were found unlocked and unattended, which was confirmed by staff members. Specifically, on the [NAME] Hall, a treatment cart was left unlocked and unattended by an RN. Similarly, two medication carts on the 200 hall were also found in the same condition, which was acknowledged by the RN on duty. Additionally, the facility did not adequately manage the expiration of medications. An LPN discovered expired Lantus insulin in a medication cart, and further inspection revealed that the emergency medication refrigerator was unlocked. Expired medications, including fish oil supplements and influenza vaccines, were found in the medication storage room and confirmed by staff to be past their expiration dates. The DNS expressed that the expectation was for all carts and refrigerators to be locked and free of expired medications.
Deficiencies in Care Plan Implementation for Fall Prevention and Medication Management
Penalty
Summary
The facility failed to develop and implement person-centered care plans for two residents, leading to deficiencies in fall prevention and medication management. Resident 3, admitted with congestive heart failure, was identified as being at moderate risk for falls. Despite a care plan intervention to keep the bed in a low position to minimize fall risk, observations revealed the bed was at a normal height. Staff, including a CNA and RNCM, were unaware or did not implement the fall prevention strategies outlined in the care plan, increasing the resident's risk of falls. Resident 8, admitted with a pulmonary embolism and acute cor pulmonale, was prescribed Apixaban, a high-risk anticoagulant medication. However, the resident's care plan did not include monitoring for this high-risk medication. The DNS confirmed that the care plan should have included monitoring for high-risk medications like anticoagulants, but it did not, indicating a failure in medication management for Resident 8.
Failure to Administer Medication as Prescribed
Penalty
Summary
The facility failed to adhere to physician orders for medication administration for a resident diagnosed with paroxysmal atrial fibrillation, hemiplegia due to a stroke, and high blood pressure. The resident was prescribed 5 mg of apixaban to be administered twice daily to prevent blood clotting. However, the Medication Administration Records (MARs) for June and July 2024 showed multiple instances where the resident refused the medication, particularly in the evenings. Despite the refusals being documented, there was no evidence of effective interventions to ensure the resident received the prescribed medication. Interviews with facility staff revealed that the resident had a known pattern of refusing medications in the evenings, especially after going to bed. Staff attempted to address this by extending the medication administration window from two hours to four hours in the evening. However, this intervention did not resolve the issue, as the pattern of refusals persisted. The facility did not implement additional strategies to address the ongoing refusals, which placed the resident at risk for medical complications due to the lack of consistent medication administration.
Failure to Ensure Regular Physician Visits for Resident
Penalty
Summary
The facility failed to ensure that residents were seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. This deficiency was identified for one of the five sampled residents reviewed for medications. The resident in question was admitted to the facility in July 2023 with a diagnosis of atrial fibrillation, a condition characterized by an irregular and often rapid heart rate. A review of the resident's health record revealed no documented physician visits since admission. Interviews with facility staff confirmed that the resident had not been seen by their primary care physician since admission, despite the facility's policy requiring regular physician visits within the specified timeframes.
Expired COVID-19 Vaccines Administered to Residents
Penalty
Summary
The facility failed to ensure that expired COVID-19 vaccines were not administered to two residents, leading to a significant medication error. Resident 19, who was admitted with diagnoses including congestive heart failure and had moderately impaired cognition, received an expired COVID-19 vaccine. This occurred because Staff 8, an RN, was distracted and did not check the expiration date before administering the vaccine. Similarly, Resident 36, admitted with a fracture of the left femur and also with moderately impaired cognition, received an expired COVID-19 vaccine under the same circumstances. Staff 8 admitted to being distracted and failing to verify the expiration date. Staff 2, the DNS, stated that it was expected that expired vaccines would be disposed of promptly. Both residents were placed on alert charting and monitored for adverse side effects following the administration of the expired vaccines.
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A resident with acute respiratory failure and heart failure had a documented Full Code status and a POLST specifying Attempt Resuscitation/CPR and Full Treatment. During night rounds, two CNAs found the resident not breathing, cool to the touch, with yellow skin and no pulse, but did not initiate CPR or call a code blue, instead going to notify an LPN. The LPN assessed the resident, confirmed absence of vital signs, noted the body was cold with mottling and no rigor mortis, and contacted the DNS, physician, and 911 for the coroner’s number, but did not start CPR or activate a code blue. No lifesaving measures were attempted despite facility policy requiring CPR for unresponsive residents without a valid DNR and the resident’s clearly documented full code status, leading surveyors to cite Immediate Jeopardy and substandard quality of care.
A resident with respiratory failure and pneumonia, who was Full Code and not on hospice, was found during routine rounds and suspected to be deceased. Nursing staff assessed the resident, noted there was no rigor mortis, confirmed death, and did not initiate a code blue or any resuscitation efforts despite the resident’s Full Code status. The facility later treated this as a potential neglect incident but did not report it to the State Agency within the required two-hour timeframe, as confirmed by the regional QA director.
A resident with chronic pain and a left below-knee amputation, who required supervision or touching assistance with ADLs, was discharged after returning from an outing shortly after midnight. Although discharge instructions noted the need for assistance and assistive devices, there was no documentation of referrals for medical equipment or home health services. Facility staff documented that the resident was discharged because they were out past midnight and believed Medicare would not cover the stay, did not issue a NOMNC, and recorded the discharge as voluntary despite the resident later reporting they had been “kicked out” and were sleeping on a friend’s couch with difficulty getting around. Staff interviews revealed no financial issues and indicated the resident had originally been scheduled for discharge at a later date.
A resident with a hip fracture and anxiety reported to social services that a CNA had been rough, told the resident to take themself to the bathroom, and instructed them not to get out of bed until a specified early morning time. The allegation was received by facility staff in the late afternoon, but the incident report was not submitted to the State Agency until the following day, exceeding the required 2-hour reporting timeframe acknowledged by the DNS. The deficiency concerns this untimely reporting of an abuse allegation, despite the CNA’s denial of any abuse.
A resident with hemiplegia, previously evaluated as not appropriate to self-administer any medications, was found to have open tubes of antifungal cream, anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) stored in a bedside drawer. Record review showed there were no MD orders for several of these topical products and no order permitting self-administration. An RN case manager confirmed the absence of orders, and the resident reported self-administering the medications, demonstrating a failure to ensure medications were administered only as ordered and in accordance with the resident’s assessed ability.
A resident with hemiplegia, previously evaluated as not appropriate to self-administer medications, was found with open containers of anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) in a bedside drawer. Record review showed no MD orders, no documented indication for use, and no monitoring for these medications. An RN case manager confirmed there were no orders and that staff did not administer or monitor the creams, while the resident reported self-administering them.
The facility failed to investigate multiple staff-reported allegations that one cognitively intact, wheelchair-using resident engaged in sexually inappropriate behaviors toward three other residents with significant cognitive and neurological impairments. Staff reported finding a resident with a ripped brief, crying and resisting care, and suspected sexual contact; they also reported that the alleged aggressor tried to take another resident into a shower room for sexual acts, attempted to video and kiss that resident, and encouraged a third resident to remove their top while present with a phone. CNAs, social services, and other staff stated they informed the administrator, DNS, HR, and unit management about these incidents and behaviors, but the administrator acknowledged that no investigations were conducted, despite being aware of the reports.
A resident with multiple sclerosis, care planned as dependent on two staff and requiring a Hoyer lift for transfers, was instead transferred by a CNA using a stand-pivot method without the lift or a second staff member. The CNA reported she had not read the resident’s care plan and described performing the transfer by giving the resident a “giant bear hug” and making several attempts to move the resident from chair to bed. The resident reported right flank pain and stated the transfer caused three broken ribs, although an x-ray later showed no rib fractures or dislocation and no visible injury was noted.
A resident with multiple sclerosis was admitted with physician orders for PT and OT, but review of the clinical record showed no documentation that these therapies were ever provided. The resident reported not receiving any therapy since admission, and the Director of Rehabilitation confirmed that no therapy services had been delivered during this period despite active orders, resulting in a failure to provide ordered rehabilitative services.
A dependent resident with dementia and a history of stroke, identified on the MDS as requiring staff assistance for showers, did not consistently receive scheduled bathing, and one CNA falsely documented that bathing had been provided. CNA task reports showed missed or undocumented baths on scheduled days, and an internal investigation confirmed that a bath recorded as completed on one date had not actually occurred. Staff interviews indicated that if bathing was not documented it usually did not occur, and that scheduled bathing was expected to be provided by staff.
Failure to Initiate CPR for a Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide CPR in accordance with a resident’s documented full code status. The facility’s Emergency Procedure CPR policy, initiated in 2001, required staff trained in CPR to initiate resuscitation on unresponsive residents who were not breathing unless there was a valid DNR order or clear signs of irreversible death such as rigor mortis. The policy further specified that if a resident’s DNR status was unclear, CPR should be started and continued until a DNR was confirmed. Resident 3 had been admitted with diagnoses including acute respiratory failure and heart failure and had a care plan and POLST on file indicating Full Code/Attempt Resuscitation and Full Treatment, including use of intubation, advanced airway interventions, mechanical ventilation, and transfer to hospital or ICU if indicated. On the night of the incident, a CNA (Staff 5) documented last vital signs for the resident at approximately 10:45 PM, with oxygen saturation of 92% on one liter of oxygen. At 2:00 AM, the resident was observed sleeping, breathing, and with a dry brief. Around 4:00 AM, Staff 5 and another CNA (Staff 8) entered the resident’s room and observed that the resident was not breathing, had yellow skin color, was cool to the touch, and had no palpable pulse. Both CNAs concluded the resident was deceased and went to notify the LPN (Staff 4) instead of initiating CPR or calling a code blue, despite having recent CPR training and later stating that, in retrospect, they would have started CPR and called for a code blue. When Staff 4 (LPN) entered the room, she assessed the resident and found no pulse, blood pressure, or respirations, noted the body was cold, with some mottling on the lower legs, pale/yellowish skin color, and no rigor mortis. Staff 4 did not initiate a code blue or CPR and instead contacted the DNS (Staff 2) and the physician, and then called 911 to obtain the coroner’s phone number. No lifesaving measures were attempted by any staff, despite the resident’s documented full code status and the facility policy requiring CPR in the absence of a valid DNR or signs of irreversible death. The DNS later stated she expected staff to call a code blue immediately, start CPR, call 911, and verify the resident’s code status. Surveyors determined that the facility failed to provide CPR according to the resident’s code status, placing all residents with full code status at risk and constituting substandard quality of care, with the noncompliance cited as Immediate Jeopardy and Past Noncompliance.
Removal Plan
- Administrator, DNS and nursing staff would be re-educated on the code blue process, how to locate a resident's code status in PCC and the POLST on file, and the importance of following individual resident care plans and orders.
- Resident code status would be cross-referenced with the PCC order, POLST scanned in binder, care plan, and resident dashboard.
- DNS or designee would monitor resident code status preferences for new admissions/returning admissions from hospitalizations.
- DNS or designee would audit code status for all new admissions and readmissions from hospitalization or ED visits, and share audit results with the QAPI committee to ensure substantial compliance is maintained.
- DNS or designee would complete a mock code.
- DNS or designee would complete mock codes.
Failure to Timely Report Alleged Neglect Involving Lack of CPR for Full Code Resident
Penalty
Summary
The facility failed to timely report an allegation of potential neglect related to CPR to the State Agency for one resident. The resident was admitted in February 2026 with diagnoses including respiratory failure and pneumonia and had a Full Code status, was not on hospice, and therefore was to receive CPR if found unresponsive. According to the facility’s investigation dated six days after the resident’s death, staff found the resident during routine rounds and suspected the resident was deceased, notified the nurse, and the nurse confirmed the resident was deceased. The investigation documented that at the time of the nurse’s assessment the resident did not have rigor mortis, yet the nurse did not initiate a code blue or any resuscitation interventions despite the Full Code status. The incident, which occurred on an identified date, was not reported to the State Agency until a later identified date, and the Regional Director of Quality Assurance confirmed that the facility did not report the incident within the required two-hour timeline. This failure to timely report the allegation of potential neglect involving the lack of CPR initiation for a Full Code resident constituted the deficiency identified by surveyors.
Failure to Ensure Safe and Orderly Discharge After Late Return from Outing
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and orderly discharge for a resident who was admitted with chronic pain, a left below-knee amputation, and post-surgical aftercare needs. An admission MDS completed shortly after admission documented that the resident was cognitively intact but required supervision or touching assistance with toileting, transfers, and bathing. Discharge instructions indicated the resident was being discharged home and that the resident’s current physical status required assistance and assistive devices, yet there was no documentation of referrals for needed medical equipment or a home health referral. The facility’s records did not show that these services or equipment were arranged prior to discharge. On the night in question, a nursing note documented that the resident returned to the facility after an outing at 12:23 AM, after the facility had notified the police because the resident’s location was unknown. The resident reported having been out with friends and being unaware of any concern. A social services note stated that because the resident was out past midnight, the resident was discharged from the facility, and a NOMNC was not issued because the resident left prior to the scheduled discharge and on their own initiative. A discharge summary documented that discharge instructions were reviewed with the resident, who refused to sign and was leaving voluntarily, and the voluntary consent form included a handwritten statement that the resident refused to sign. Later, the resident stated they had been “kicked out” for coming back late and were sleeping on a friend’s couch, finding it difficult to get around. Staff interviews showed there were no financial issues documented, that staff believed Medicare would not cover the resident if out past midnight, and that the resident had been scheduled for discharge several days later, while a regional director later characterized the situation as a clerical error and confirmed a normal discharge should have been completed.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to timely report an allegation of abuse to the State Agency after a resident reported that a CNA had been rough and verbally directive with them. The resident, who had been admitted with diagnoses including a hip fracture and anxiety, stated that the CNA was “kind of rough,” told the resident to take themself to the bathroom, and instructed the resident not to get out of bed until 6:00 AM. The resident reported this allegation of abuse involving the CNA to the social services staff member at 4:00 PM on 1/29/26. According to the facility’s investigation documentation, the allegation was received by staff at 4:00 PM on 1/29/26, and the Facility Reported Incident form was not received by the State Agency until 2:13 PM on 1/30/26. The DNS acknowledged that the facility became aware of the allegation at 4:00 PM on 1/29/26 and that it should have been reported to the State Agency within two hours but was not. The CNA denied abusing the resident or any resident, but the deficiency centers on the delay in reporting the allegation to the State Agency within the required timeframe.
Failure to Prevent Unauthorized Self-Administration of Non-Prescribed Medications
Penalty
Summary
Surveyors identified that a resident was self-administering non-prescribed topical medications despite a documented determination that they were not appropriate to self-administer any medications. The resident, admitted with hemiplegia, had a Self-Medication Administration Evaluation dated 11/13/25 indicating they were not appropriate to self-administer medications. During an observation on 3/19/26 at 7:50 AM with a RN case manager, open tubes of antifungal cream, anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) were found in the resident’s bedside table drawer. Review of the clinical record showed there were no physician orders for the anti-itch cream, hydrocortisone cream, or DMSO, and the resident did not have an order to self-administer any medications. The RN case manager confirmed the lack of orders for these medications, and at 8:10 AM the resident stated they did self-administer the medications found in their room. This constituted a failure by the facility to ensure the resident did not self-administer non-prescribed medications and to provide treatment and care according to physician orders and the resident’s evaluated ability to self-administer medications.
Unmonitored Self-Administration of Topical Medications Without Physician Orders
Penalty
Summary
The facility failed to ensure a resident’s drug regimen was free from unnecessary drugs by not providing adequate monitoring, indication for use, or physician orders for multiple medications. A resident admitted with hemiplegia in May 2024 had a self-medication administration evaluation dated 11/13/25 indicating they were not appropriate to self-administer any medications. During an observation on 3/19/26, an RN case manager found an open tube of anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) in the resident’s bedside table drawer. Record review showed no physician orders, no documented indication for use, and no monitoring for these medications. The RN case manager confirmed the resident did not have orders for the anti-itch cream, hydrocortisone cream, or DMSO, and that staff did not administer or monitor these medications. The resident stated they self-administered the medications found in their room, despite the prior evaluation determining they were not appropriate to self-administer any medications.
Failure to Investigate Multiple Allegations of Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to investigate multiple allegations of sexual abuse involving three residents. Resident 102, who had cognitive loss equivalent to a young child, legal blindness, and was non-verbal, was reportedly found with a ripped brief, crying, and resisting a brief change. Staff reported concerns that another resident, Resident 105, had performed or attempted to perform sexual acts on Resident 102. Staff members, including CNAs and social services, stated they informed facility management, including the Administrator and DNS, about the torn brief, Resident 102’s distress, and concerns that Resident 105 was being sexually inappropriate with multiple residents. Despite these reports and discussions in morning meetings, the Administrator acknowledged that no investigation was completed, believing the incident was based on staff assumptions. The facility also failed to investigate allegations involving Resident 103, who had Alzheimer’s disease and Parkinson’s disease. Staff reported that Resident 105 attempted to take Resident 103 into a shower room to perform sexual acts, and that a staff member intervened. The complainant later spoke with Resident 103, who stated that Resident 105 was “sick” and made bad comments. Other staff reported to human resources, the DNS, and the Administrator that Resident 105 attempted to take a resident into a shower room to unclothe the resident, and that Resident 105 attempted to video Resident 103, expressed a desire to kiss Resident 103, and get the resident into a shower room. The Social Service Director confirmed she reported these concerns to the Administrator, who stated he was aware of the incident but that no investigation was completed. A third failure to investigate involved Resident 108, who had Huntington’s disease and dementia. A staff member reported observing Resident 105 telling Resident 108 to take off their shirt and gesturing for them to do so, and stated they completed a written statement and gave it to the unit manager. Another CNA reported hearing that Resident 105 and other residents were laughing and encouraging Resident 108 to remove their top, and also reported observing Resident 105 rubbing other residents’ backs more physically than appropriate. Social services reported being told that Resident 108 was removing their top while Resident 105 was in the dining room with a phone, and that Resident 105 admitted to the behavior but described it as innocent. The Administrator stated he was aware of Resident 108 removing their shirt while Resident 105 was present, yet confirmed that no investigation was completed for this incident. These failures to investigate led surveyors to determine that the facility did not respond appropriately to alleged violations of sexual abuse for the three residents.
Removal Plan
- Residents 102, 103, and 108 received head-to-toe skin assessments completed by RCMs with no observed findings.
- Resident 105 was placed on one-to-one observations pending investigations.
- Staff 1 (Administrator) and Staff 2 (DNS) were re-educated on the facility's abuse policy, reporting, and thorough investigations.
- Social Services will interview all interviewable residents regarding abuse.
- Nurses will complete a head-to-toe assessment on all non-interviewable residents.
- All staff, including agency staff, will be re-educated on the facility's abuse policy and reporting.
Failure to Follow Care-Planned Hoyer Lift Transfer Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow a resident’s care plan interventions for transfers, resulting in a transfer being performed without required equipment and assistance. A resident admitted in February 2026 with multiple sclerosis had a 2/25/26 ADL care plan indicating the resident was dependent on two staff members for transfers and required use of a Hoyer (mechanical) lift. Despite this, on 2/28/26 a CNA (Staff 3) performed a stand-pivot transfer without the Hoyer lift and without a second staff member. The resident later reported that Staff 3 gave a “giant bear hug” and made several attempts to transfer the resident from chair to bed, after which the resident reported right flank pain and stated the transfer caused three broken ribs. An x-ray on 3/10/26 showed no rib fractures or dislocation, and the resident was assessed to have no visible injury. During interview, Staff 3 confirmed she had completed a stand-pivot transfer with the resident and acknowledged she had not read the resident’s care plan, and the Administrator confirmed that the resident had been care planned for a two-person Hoyer lift transfer at the time of the incident.
Failure to Provide Ordered Rehabilitative Services
Penalty
Summary
The facility failed to provide ordered rehabilitative services to a resident with multiple sclerosis. The resident was admitted in February 2026 with admission orders dated 2/24/26 for both physical therapy and occupational therapy. Review of the resident’s clinical record showed no documented evidence that any therapy services were provided as ordered. In an interview on 3/11/26 at 10:58 AM, the resident reported not having received any therapy since admission. During a separate interview on 3/11/26 at 10:40 AM, the Director of Rehabilitation confirmed that the resident had not received any therapy services from the date of admission through 3/11/26, despite the existing orders for physical and occupational therapy. This failure to implement the physician’s orders for rehabilitative services for this resident placed the resident at risk for a decline in range of motion.
Failure to Provide and Accurately Document Scheduled Bathing for a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a dependent resident received required assistance with activities of daily living (ADLs), specifically bathing, and inaccurate documentation that bathing had been provided. The resident, admitted in 10/2025 with dementia and stroke, had a 10/21/25 admission MDS indicating severe cognitive impairment and dependence on staff for showers. The facility’s 12/2025 CNA task report showed the resident was scheduled for bathing on day shift on Wednesdays and Sundays. On 12/24/25, the task report was blank for bathing, and on 12/28/25, the report documented that the resident received bathing and was dependent on staff for assistance. However, a 12/29/25 facility investigation determined the resident did not receive a bath on 12/28/25 and that it had been falsely documented that bathing occurred. A Facility Reported Incident form dated 12/31/25 further documented that on 12/28/25, a CNA (Staff 5) noted providing bathing to the resident but did not provide any type of bathing. Additional record review showed that the resident’s 3/2026 CNA task report contained no documentation that any type of bathing was provided on 3/11/26. Attempts to contact Staff 5 on 3/16/26 and 3/17/26 were unsuccessful. During interviews, another CNA (Staff 7) stated that on 12/28/25 she observed Staff 5 lay the resident down and, when she asked about bathing, Staff 5 said she would complete the resident’s bathing in the evening; Staff 7 stated she could not perform the resident’s bathing in the evening because she moved to a different hall on evening shift. Another CNA (Staff 21) stated that usually if bathing was not documented in the resident’s record, bathing did not occur. The Regional Nurse (Staff 31) stated that staff should provide scheduled bathing to residents.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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