Rose City Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Portland, Oregon.
- Location
- 11325 Ne Weidler Street, Portland, Oregon 97220
- CMS Provider Number
- 38E157
- Inspections on file
- 18
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Rose City Nursing And Rehabilitation during CMS and state inspections, most recent first.
The facility did not maintain the required RN coverage for at least eight consecutive hours per day, seven days a week, as per their policy. Over a period of three months, there were 33 days without appropriate RN coverage, which was acknowledged by the facility's administrators.
The facility failed to properly label and store food and beverages in all kitchen and unit refrigerators, risking spoilage and cross-contamination. Observations revealed unlabeled and undated items, including cheese, butter, and beverages, contrary to the facility's policy and FDA guidelines. Staff confirmed the deficiency, highlighting ongoing non-compliance.
A facility failed to provide a person-centered activity program for three residents, leading to a decline in their psychosocial well-being. One resident, unable to participate in activities due to mobility issues, was isolated in their room. Another resident, interested in art and music, reported a lack of enrichment activities. A third resident expressed interest in group activities but was rarely invited. The Activity Director's dual responsibilities contributed to missed activities and inadequate documentation.
The facility was found deficient for not having a qualified professional to direct the activities program. The Activity Director/Social Services Director admitted to not having the necessary certification or training, which was confirmed by the Administrator. This deficiency posed a risk to residents' physical, mental, and psychosocial needs.
Expired medications were not properly disposed of in a facility, as observed in a resident medication storage refrigerator and a medication storage room. An LPN confirmed an expired multi-dose vial of Tuberculin, and an Administrator-In-Training verified expired bottles of lotion. The facility's policy did not adequately address the disposal of vials, leading to potential risks for residents.
A resident with congestive heart failure was not assessed for smoking safety upon admission, as required by the facility's policy. The resident was observed smoking independently without prior evaluation, and staff later acknowledged the oversight. The resident was not listed among those who smoke, despite having smoking supplies and smoking independently since admission.
A resident with end-stage renal disease did not receive consistent dialysis communication and monitoring from the facility. The facility failed to complete necessary Dialysis Communication Forms on multiple occasions and did not contact the dialysis center to obtain missing information. The resident reported inconsistent assessments upon returning from dialysis, and staff confirmed the lack of communication and documentation.
A facility failed to provide a transfer notice with appeal rights to a resident or their representative and did not notify the Office of the State Long-Term Care Ombudsman of the resident's hospitalization. The resident, admitted with hypothermia and sepsis, was transferred to the hospital without the required documentation. Staff confirmed the oversight and lack of awareness regarding the notification requirement.
The facility failed to post accurate and complete staffing information as required by their policy. A review of Direct Care Staff Daily Reports (DCSDRs) from January to February revealed inaccuracies on 11 days. The Administrator and Administrator-In-Training confirmed these deficiencies, acknowledging the reports did not meet expected standards.
Inadequate RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was available for at least eight consecutive hours per day, seven days a week, as required by their policy. This deficiency was identified through interviews and record reviews, which revealed that for 33 out of 61 days reviewed, there was a lack of appropriate RN coverage. Specifically, in July 2024, four days lacked RN coverage; in August 2024, twelve days were without coverage; and in September 2024, seventeen days were identified without the required RN presence. The facility's Staffing, Sufficient and Competent Nursing Policy, last revised in August 2022, mandates RN services for at least eight consecutive hours every 24 hours, seven days a week. The facility's administrators acknowledged the challenge in maintaining RN coverage during the reviewed period.
Improper Food Labeling and Storage in Facility Refrigerators
Penalty
Summary
The facility failed to ensure that food and beverages were labeled and stored properly to minimize spoilage and cross-contamination in all four kitchen refrigerators and the unit refrigerator reviewed. This deficiency was identified during a kitchen tour and subsequent observations, where numerous food items, including cheese slices, grated substances, pitchers of red liquid, butter cubes, and blocks of cheese, were found unlabeled and undated. Staff members, including a cook and the dietary manager, confirmed these items were not properly labeled or dated, which is against the facility's Food Receiving and Storage Policy and the US FDA 2022 Food Code. Additionally, the residents' refrigerator contained several unlabeled and undated food and beverage items, such as opened bottles of soda, cola, and tea, as well as a dirty cloth bag with various food items. Staff confirmed these items were improperly stored, raising concerns about cross-contamination. The dietary manager reiterated the expectation that all food and beverage items should be labeled and dated, yet the follow-up visit revealed continued non-compliance with labeling and dating requirements.
Failure to Provide Person-Centered Activity Program
Penalty
Summary
The facility failed to provide an ongoing person-centered activity program for three residents, leading to a decline in their psychosocial well-being and quality of life. Resident 10, who was admitted with diagnoses including non-traumatic subarachnoid hemorrhage and mild cognitive impairment, was very social and enjoyed activities such as watching old TV shows and playing bingo. However, due to mobility issues, Resident 10 was unable to participate in activities held downstairs and was observed isolated in their room without access to preferred activities. Scheduled activities like bingo did not occur, and the resident expressed frustration over the lack of social interaction and activities. Resident 20, diagnosed with end-stage renal disease and major depressive disorder, also experienced a lack of engagement in activities. Despite having interests in music, nature, and art, Resident 20 reported being confined to their room with limited access to art supplies and enrichment activities. Observations confirmed the absence of scheduled activities, and the resident voiced concerns about the lack of opportunities to engage in preferred activities and socialize with others. Resident 5, with a diagnosis of heart failure, expressed interest in participating in group activities but was rarely invited or able to participate due to the infrequent occurrence of scheduled activities. The Activity Director, who was also responsible for social services and medical records, acknowledged the challenges in fulfilling their role, resulting in missed activities and inadequate documentation of resident participation. The facility's failure to provide adequate staffing and resources for the activities program contributed to the deficiency.
Unqualified Activity Director Puts Residents at Risk
Penalty
Summary
The facility failed to provide a qualified professional to direct the activities program, which was identified during a survey. Staff 11, who held the position of Activity Director/Social Services Director, stated that he was responsible for organizing and leading activities. However, he admitted that he was informed that a certification was not necessary for the role of Activity Director and confirmed that he had neither started nor completed the required training. This was corroborated by Staff 1, the Administrator, who confirmed that Staff 11 did not possess the necessary Activity Director certification. This deficiency placed residents at risk for unmet physical, mental, and psychosocial needs.
Expired Medications Not Properly Disposed
Penalty
Summary
The facility failed to properly dispose of expired medications, which was identified during an observation, interview, and record review. In the resident medication storage refrigerator, an open and used multi-dose vial of Tuberculin, with an open date of 1/22/25, was found on 2/24/25 at 11:33 AM. Staff 12, an LPN, confirmed the expiration and stated that the facility policy was to discard open vials after 30 days. Additionally, in the medication storage room, two bottles of lotion with expiration dates of 9/2022 and three bottles with expiration dates of 3/2023 were found. Staff 2, an Administrator-In-Training, verified these findings and stated that the facility policy was to dispose of expired medications and order replacements if necessary. These deficiencies placed residents at risk for lack of medication efficacy and adverse reactions from expired medications, as the facility's Storage of Medications policy did not adequately address the disposal of vials of medications, despite the manufacturer's instructions for Tuberculin vials.
Failure to Assess Resident for Smoking Safety
Penalty
Summary
The facility failed to assess the safety of a resident for smoking, which placed the resident at risk for unsafe smoking. According to the facility's Smoking Policy for Residents, a smoking assessment should be conducted upon admission, evaluating the resident's current level of tobacco consumption, method of tobacco consumption, desire to quit smoking, and ability to smoke safely with or without supervision. Resident 19, who was admitted in January 2025 with a diagnosis of congestive heart failure, did not have a smoking assessment completed, nor was it determined if the resident was an independent smoker. On February 23, 2025, a list of residents who smoke was provided by the Administrator, and Resident 19 was not included. However, on February 25, 2025, Resident 19 was observed independently entering the smoking area with smoking supplies. The Administrator later entered the smoking area and took Resident 19's cigarettes and lighter, stating an intention to conduct a smoking assessment. A CNA confirmed that Resident 19 had been keeping their own smoking supplies and smoking independently since admission. The DNS/RNCM acknowledged that Resident 19 should have been assessed for smoking safety prior to being allowed to smoke independently.
Failure in Dialysis Communication and Monitoring
Penalty
Summary
The facility failed to ensure proper dialysis services and communication for a resident with end-stage renal disease who was dependent on dialysis. The resident, admitted in August 2024, required dialysis three times a week. However, the facility did not consistently complete the necessary Dialysis Communication Forms on specific dates, namely 2/4/25, 2/6/25, and 2/15/25. This lack of documentation meant there was no pre-dialysis and post-dialysis information available for these dates, and there was no evidence that nursing staff contacted the dialysis center to obtain the required reports. The resident reported that the facility did not always assess them upon returning from dialysis, sometimes waiting several hours before doing so. Staff 3, identified as DNS/RNCM, confirmed the absence of the required communication forms and acknowledged that the facility did not contact the dialysis center to retrieve the missing information. The expectation was for the facility to maintain consistent communication with the dialysis center through the Dialysis Communication Form for each visit, which was not adhered to, leading to the deficiency.
Failure to Provide Transfer Notice and Notify Ombudsman
Penalty
Summary
The facility failed to provide a transfer notice with appeal rights in writing to a resident or their representative, and also failed to notify the Office of the State Long-Term Care Ombudsman of the resident's hospitalization. This deficiency was identified during a review of the health record of a resident who was admitted to the facility with diagnoses including hypothermia and sepsis. The resident, who was cognitively intact, was transferred to the hospital, but there was no evidence in the health record that a transfer notice with appeal rights was provided to the resident or their representative. Additionally, the facility did not notify the Office of the State Long-Term Care Ombudsman about the resident's hospitalization. During an interview, Staff 3, a DNS/RNCM, confirmed that a transfer notice was supposed to be sent with the resident at the time of transfer and that the RNCM was responsible for ensuring the notice was given. Staff 3 also admitted to being unaware of the requirement to notify the Ombudsman at the time of transfer, verifying that neither the transfer notice was given nor the Ombudsman was notified, contrary to the facility's bed hold policy.
Inaccurate and Incomplete Staffing Information
Penalty
Summary
The facility failed to post accurate and complete staffing information, as required by their Staffing, Sufficient and Competent Nursing Policy, which was last revised in August 2022. This policy mandates that direct care daily staffing numbers be posted for every shift. A review of the facility's Direct Care Staff Daily Reports (DCSDRs) from January 21, 2025, through February 22, 2025, revealed that on 11 out of 32 days, the reports were incomplete or inaccurate. The specific dates identified with deficiencies were January 23, 24, 29, 30, 31, and February 12, 13, 14, 20, 21, and 20. On February 25, 2025, at 4:01 PM, the Administrator and Administrator-In-Training confirmed the inaccuracies and incompleteness of the DCSDRs for the identified days, acknowledging that the reports did not meet the expected standards of accuracy and completeness.
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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