Rose Haven Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Roseburg, Oregon.
- Location
- 740 Nw Hill, Roseburg, Oregon 97471
- CMS Provider Number
- 385151
- Inspections on file
- 20
- Latest survey
- March 4, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Rose Haven Nursing Center during CMS and state inspections, most recent first.
The facility failed to prevent accidents and ensure smoking safety for two residents. One resident, with impaired cognition and a fall risk, was left unsupervised, resulting in a fall and hip fracture. Another resident, with paraplegia and nicotine dependence, used electronic cigarettes in non-designated areas due to unclear smoking safety protocols. Staff were aware but did not enforce safety measures.
The facility failed to follow infection control standards, with multiple staff members not adhering to Enhanced Barrier Precautions (EBP) and proper hand hygiene. A resident with necrotizing fasciitis was not placed on EBP, and staff did not follow proper procedures during dressing changes and handling of medical supplies. Housekeeping staff also failed to properly dispose of PPE, leading to potential contamination risks.
The facility failed to maintain accurate narcotic records and provide timely medications, affecting two residents. Narcotic log books showed missing staff signatures for verification, and two residents did not receive prescribed medications due to unavailability, with staff failing to notify the DNS.
The facility failed to provide adequate care for residents, including improper wound management, insufficient fall response, and delayed infection treatment. A resident with a venous wound did not receive required evaluations, another experienced multiple falls without proper neurological checks, and a third was not premedicated as prescribed before a painful dressing change. Additionally, a resident with a yeast infection faced delays in treatment due to inconsistent staff communication and care plan updates.
A facility failed to develop an individualized care plan for a resident with a colostomy and necrotizing fasciitis requiring a wound vac. The care plan did not address the necessary care and services for these conditions. Staff members were unaware of the specific care required, and the DNS acknowledged the care plan was not person-centered.
A resident with a history of stroke and dysphagia was inadequately monitored for dehydration, with fluid intake consistently below recommended levels. Despite showing signs of dehydration, such as dry mouth and poor skin turgor, staff failed to provide timely fluids and did not document the resident's condition properly. Interviews revealed staff were unsure how to assess dehydration, leading to inadequate care and increased risk for the resident.
The facility failed to manage pain effectively for two residents, one with chronic pain and spinal fusion, and another with diabetes and neuropathy. The first resident did not receive scheduled gabapentin and inconsistent application of Biofreeze, affecting pain management. The second resident received pain medications without documented pain levels, and their care plan lacked non-pharmacological interventions and monitoring for side effects. Both residents experienced inadequate pain management due to these deficiencies.
A facility failed to provide adequate care for a resident with dementia, who exhibited behaviors such as rejection of care and aggression. Despite a care plan outlining interventions, there was no documentation of attempts to reduce these behaviors or their success. Staff interviews indicated the resident's behaviors were linked to incontinence and being woken up early, but interventions were not consistently documented.
A resident with paraplegia and existing pressure ulcers was admitted to the facility, but the initial assessment failed to document a purple area on the right anterior ankle. This wound was not treated until it opened and was later identified as a Stage 2 pressure wound. The care plan also did not include this wound, leading to a delay in treatment.
A resident with heart failure and COPD was mistakenly provided with a CPAP machine instead of the physician-ordered BiPAP machine, leading to inappropriate respiratory care. The error was discovered after a complaint, and staff confirmed the wrong equipment was delivered by the respiratory company. The resident's oxygen saturation levels were affected until the issue was identified.
The facility failed to document the indication for use of antibiotics for two residents, leading to a deficiency in ensuring drug regimens were free from unnecessary drugs. One resident was prescribed multiple antibiotics without documented reasons, and another received Cephalexin without a documented indication. The DNS acknowledged the lack of documentation.
Failure to Prevent Accidents and Ensure Smoking Safety
Penalty
Summary
The facility failed to ensure a safe environment for Resident 25, who was at risk of falls due to impaired cognition and difficulty walking. Despite the care plan indicating that the resident's bed should be in a lowered position, Staff 42, a CNA, did not follow this directive. As a result, Resident 25 fell and sustained a hip fracture, requiring surgery. The incident investigation revealed that the resident was left unsupervised during a bed change, leading to the fall. Staff 42 acknowledged the resident's need for two-person assistance, yet left the resident alone, resulting in the accident. Resident 283, who was admitted with paraplegia and nicotine dependence, was also subject to inadequate supervision regarding smoking safety. The resident was observed using electronic cigarettes in non-designated areas, contrary to the facility's smoking agreement, which was reportedly not signed by the resident. Staff were aware of the resident's smoking habits and assisted them in and out of the building, yet failed to enforce the smoking safety protocols. The facility's smoking contract did not clearly address electronic cigarette use, leading to a lack of proper oversight and potential safety hazards.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to infection control standards, as observed in multiple instances involving staff and residents. Resident 77, who was admitted with necrotizing fasciitis and had a wound vac and colostomy, was not placed on Enhanced Barrier Precautions (EBP) as required. During a dressing change, Staff 40 did not follow proper infection control procedures, such as wearing a gown, setting up a clean field, or changing gloves and sanitizing hands between tasks. This led to contamination risks as clean dressing supplies were placed on a dirty bed, and the staff member handled the wound and other items with dirty gloves. In another instance, Staff 33, an agency CNA, failed to perform hand hygiene before and after entering rooms with EBP and Droplet Precautions, and continued to handle items and enter other rooms without sanitizing hands. Similarly, Staff 34 did not sanitize hands after handling soiled linen. Resident 43 expressed discomfort with having blood sugar taken in the dining room, which was not addressed. Staff 35, an agency LPN, was unaware of the EBP requirements and did not don a gown before handling a resident's tube feeding supplies, despite signage indicating the need for PPE. Additionally, Staff 24 from housekeeping did not follow proper procedures for removing and disposing of PPE, mixing soiled gowns with clean ones outside the resident's room. This was due to confusion about the process, as confirmed by Staff 25, the Housekeeping Manager, and Staff 10, the Infection Preventionist. The facility's administrator acknowledged that staff were expected to wear and discard PPE appropriately, but these expectations were not consistently met, leading to potential infection control breaches.
Failure to Maintain Accurate Narcotic Records and Provide Timely Medications
Penalty
Summary
The facility failed to maintain accurate narcotic drug records and provide timely pharmaceutical services, as evidenced by the review of medication carts and resident records. The narcotic log books for five medication carts showed numerous instances where staff did not sign to verify the narcotic count, with missing signatures ranging from 17 to 65 out of possible counting opportunities. This lack of verification was acknowledged by Staff 2, who confirmed that two staff members were required to count and sign off on the narcotics, and that the counts were not correct. Additionally, two residents were affected by the facility's failure to provide necessary medications. One resident, admitted with depression, did not receive prescribed antidepressants for several days because the medications were unavailable, and staff failed to alert the DNS about this issue. Another resident, with severe pressure wounds, did not receive prescribed nutritional supplements for wound healing over several days due to unavailability, and again, staff did not notify the DNS. These lapses in pharmaceutical services placed residents at risk for unmet pharmaceutical needs.
Deficiencies in Resident Care and Treatment
Penalty
Summary
The facility failed to provide adequate care and services for several residents, leading to deficiencies in wound management, fall response, medication administration, and infection treatment. Resident 6, who was admitted with heart failure and chronic kidney disease, had a venous wound on the left lateral calf that was not properly evaluated or documented after the initial assessment. Despite the facility's guidelines requiring weekly wound assessments, no further evaluations were conducted, and staff incorrectly stated that evaluations were not needed until scabs fell off. Resident 35, who had a history of stroke and difficulty walking, experienced multiple falls, including unwitnessed ones, without proper neurological checks being documented. The facility's protocol for unwitnessed falls was not followed, as evidenced by the lack of documentation for the required neurological checks after each fall. This oversight was confirmed by staff during interviews, indicating a failure to adhere to established procedures for monitoring residents after falls. Resident 77, diagnosed with necrotizing fasciitis, was not premedicated as prescribed before a dressing change, resulting in the resident experiencing pain during the procedure. The medication was administered less than an hour before the dressing change, contrary to the order. Additionally, Resident 55, who had severe obesity and diabetes, experienced delays in treatment for a yeast infection. The resident's symptoms were not addressed promptly, and there was a lack of timely implementation of physician orders for antifungal treatment. Staff communication and care plan updates were inconsistent, contributing to the delay in treatment and inadequate management of the resident's condition.
Failure to Develop Individualized Care Plan for Resident
Penalty
Summary
The facility failed to develop an individualized plan of care for a resident admitted with diagnoses including a colostomy and necrotizing fasciitis, requiring a wound vac. The care plan, last revised on February 10, 2025, did not address the necessary care and services for the resident's colostomy or wound vac. Interviews with staff members revealed that they were not aware of the specific care and services required for the resident's conditions, and these were not included in the care plan. The Director of Nursing Services acknowledged that the care plan was not person-centered and needed more details related to the colostomy and wound vac.
Failure to Monitor and Address Resident Dehydration
Penalty
Summary
The facility failed to adequately monitor, assess, and document signs and symptoms of dehydration for a resident with a history of stroke, muscle weakness, and dysphagia. The resident was admitted in 2019 and had a care plan that required staff to ensure adequate hydration and nutritional intake. Despite this, the resident's fluid intake consistently fell below the recommended levels for 26 out of 29 days, as documented in the fluid monitor records. Observations revealed that the resident frequently exhibited signs of dehydration, such as dry mouth, dry lips, and poor skin turgor. The resident repeatedly expressed thirst and requested water, yet staff failed to provide adequate fluids in a timely manner. On multiple occasions, the resident was found with empty or half-empty cups and continued to show signs of dehydration, including a coated tongue and difficulty speaking. Staff interviews indicated a lack of awareness and appropriate response to the resident's hydration needs. CNAs and LPNs were unsure how to assess for dehydration and did not consistently provide the necessary fluids. Despite the resident's clear signs of dehydration, staff did not take immediate action to address the issue, and documentation of the resident's condition was incomplete. The facility's failure to monitor and respond to the resident's hydration needs placed the resident at risk for dehydration.
Deficiencies in Pain Management for Two Residents
Penalty
Summary
The facility failed to accurately assess and manage pain for two residents, leading to deficiencies in their care. Resident 24, admitted with chronic pain and spinal fusion, experienced frequent severe pain that impacted sleep and therapy. Despite a care plan to anticipate and respond to pain, the resident did not receive scheduled gabapentin due to delays in medication delivery and lack of administration. Additionally, Biofreeze, a topical pain relief, was not consistently applied as ordered, with staff citing the resident's sleep as a reason for missed applications. The resident expressed that inconsistent application of Biofreeze affected their pain management. Resident 55, with diagnoses including diabetes with neuropathy and kidney disease, was at risk for decline due to frequent moderate to severe pain. The resident received oxycodone-acetaminophen and acetaminophen without documentation of pain levels, and their care plan lacked details on non-pharmacological interventions. There was no monitoring for side effects of pain medications, and staff confirmed the care plan's inadequacy in addressing the resident's pain management needs. The resident reported persistent pain, rarely below a level of three on a scale of zero to ten.
Failure to Document and Implement Interventions for Resident with Dementia
Penalty
Summary
The facility failed to provide adequate care and services for a resident diagnosed with dementia and borderline personality disorder. The resident, who was readmitted to the facility, was noted to have behaviors such as rejection of care, yelling, and physical aggression. Despite these behaviors being documented multiple times across different shifts, there was no evidence in the clinical record of what interventions were attempted to reduce these behaviors or if they were successful. The care plan for the resident included administering medications, anticipating needs, providing cues, and monitoring for danger to self or others, but the documentation did not reflect the implementation or effectiveness of these interventions. Interviews with staff revealed that the resident exhibited behaviors when incontinent or when woken up earlier than desired. Staff members noted that speaking to the resident sometimes helped calm them down. However, the Director of Nursing Services confirmed that staff needed to offer and document interventions for the resident's behaviors, which was not consistently done. This lack of documentation and follow-through on interventions placed the resident at risk for unmet needs.
Failure to Assess and Treat Pressure Ulcers
Penalty
Summary
The facility failed to properly assess, implement, and maintain pressure ulcer treatments and care plans for a resident admitted with pressure ulcers and paraplegia. Upon admission, the resident had a coccyx pressure wound and a wound to the left gluteal fold, but the admission assessment did not document a purple area on the right anterior ankle. The care plan created later also failed to mention this wound. It was only on a progress note that the discoloration on both ankles was acknowledged. The wound on the right anterior ankle was not treated until it opened, which was several days after admission, and was subsequently identified as a Stage 2 pressure wound. Staff acknowledged that the wound was not captured in the initial assessment and was not treated in a timely manner.
Failure to Provide Physician-Ordered Respiratory Care
Penalty
Summary
The facility failed to provide physician-ordered respiratory care for a resident diagnosed with heart failure and chronic obstructive pulmonary disease. The resident was admitted to the facility with a physician's order for a BiPAP machine, which is a non-invasive ventilation therapy used to treat sleep apnea and other breathing disorders. However, the resident was mistakenly provided with a CPAP machine instead of the ordered BiPAP machine. This error was discovered after a public complaint was received by the State Survey agency, indicating that the resident had been using the wrong equipment since admission. Observations and interviews confirmed that the resident had been using a CPAP machine instead of the prescribed BiPAP machine. The resident's oxygen saturation levels were notably low when using the CPAP, but improved significantly when switched to a nasal cannula. Staff interviews revealed that the respiratory company delivered the incorrect machine, leading to the resident receiving inappropriate respiratory care. The resident, who was cognitively intact, also confirmed the use of the wrong machine upon readmission from the hospital.
Lack of Documentation for Antibiotic Use in Residents
Penalty
Summary
The facility failed to provide adequate documentation for the indication of use of medications for two residents, leading to a deficiency in ensuring that each resident's drug regimen was free from unnecessary drugs. Resident 6, admitted with diagnoses including heart failure and shortness of breath, was prescribed multiple antibiotics such as Doxycycline Hyclate, Augmentin, and Linezolid over a period of time. However, there was no documentation in the resident's clinical record indicating the specific reasons for these antibiotics, which is a requirement for ensuring appropriate medication use. During an interview, the Director of Nursing Services (DNS) acknowledged the expectation for diagnoses to be documented for antibiotic use. Similarly, Resident 131, who was admitted with severe pressure wounds, was administered Cephalexin as indicated in the August 2024 Medication Administration Record (MAR). However, there was no documented indication of use for this antibiotic. The DNS confirmed the absence of a documented indication for the Cephalexin. These oversights in documentation placed the residents at risk for receiving unnecessary medications, as there was no clear justification for the antibiotic treatments provided.
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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