Royale Gardens Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Grants Pass, Oregon.
- Location
- 2075 Nw Highland Avenue, Grants Pass, Oregon 97526
- CMS Provider Number
- 385148
- Inspections on file
- 29
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Royale Gardens Health & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia, behavioral issues, poor safety awareness, and a history of falls was assessed as a wander risk and care planned for assisted transfers and potential one‑on‑one supervision. Despite documented agitation, aggression, pacing without assistance, and unsuccessful behavioral interventions, the resident continued to ambulate and attempt self‑transfers without adequate supervision. On one day, the resident sustained a witnessed fall while attempting to stand without help and later an unwitnessed fall near the bed after reporting having hit the head. Staff reported that the resident required two‑person assistance for safety and needed one‑on‑one supervision, but only one staff member was available and no one‑on‑one could be arranged, leading to the falls and subsequent hospitalization for subdural hematomas.
Surveyors found that multiple residents with conditions including pain, repeated falls, stroke, diabetes, and heart disease had malfunctioning call lights that did not operate independently from their roommates’ call lights. One cognitively intact resident reported long response times and that the call light would shut off on its own, and stated these concerns had been reported to staff without follow-up. A CNA initially dismissed the resident’s reports but later confirmed, along with the administrator, that several call lights were not functioning properly and that activating or turning off one resident’s call light affected the roommate’s call light.
Surveyors found that a hallway water dispenser had visible buildup on both hot and cold outlets, with no established cleaning schedule or documentation for regular outlet sanitation. Housekeeping staff reported they only cleaned the exterior of the dispenser, and maintenance staff confirmed there was no routine process for cleaning the outlets. In addition, a resident snack refrigerator contained three unlabeled pitchers of red and yellow liquids, with an LPN confirming the lack of labels and the dietary manager acknowledging that these beverages should have been dated. The administrator stated he expected staff to perform required job duties.
A resident with a history of seizures was administered multiple psychotropic medications without being informed of their side effects prior to administration. Documentation and staff interviews confirmed the lack of resident notification regarding these medications.
A resident with diabetes and a below-the-knee amputation was subjected to unwanted sexual contact by another cognitively intact resident during a group activity, where a doughnut was inappropriately used. Multiple staff and witnesses confirmed the incident, and the affected resident experienced emotional distress and avoidance behaviors for at least a week following the event.
Due to ongoing CNA staffing shortages, several residents did not receive timely incontinent care or scheduled showers, as confirmed by resident council notes, care records, and multiple staff interviews. Facility leadership acknowledged the staffing shortfall and its impact on resident care.
The facility failed to provide adequate wound care and monitoring for three residents, leading to potential risks of worsening wounds and infections. A resident with burns did not receive timely care, resulting in an infection. Two residents with surgical sites experienced delayed monitoring for signs of infection, with orders not implemented until days after admission. Staff acknowledged issues with receiving wound care instructions from hospitals.
A resident with severe cognitive impairment experienced 27 falls in two months due to the facility's failure to assess and implement effective fall prevention interventions. The care plan included frequent rounding and staff-provided care, but there was no analysis of the falls to evaluate intervention effectiveness. Staff reported inadequate staffing levels to provide necessary one-to-one care, and the facility administrator could not explain the high number of falls or lack of intervention assessment.
The facility failed to administer appropriate antibiotics for three residents, leading to significant health issues. A resident with dementia received ineffective treatment for UTIs, resulting in hospitalization and eventual death. Another resident was prescribed an ineffective antibiotic without complete culture results, and a third resident received a prescription not aligned with culture findings. These deficiencies highlight the facility's failure to ensure effective antibiotic treatments.
The facility failed to provide timely pharmaceutical services, resulting in missed doses of critical medications for three residents. A resident with a history of seizures did not receive their antiseizure medication for ten days, while another resident missed doses of Atorvastatin, and a third resident missed doses of dexamethasone and Advair inhaler. Additionally, narcotic reconciliation records were incomplete, indicating lapses in medication management protocols.
A resident with a history of seizures did not receive their prescribed antiseizure medication due to unavailability in the facility's medication dispensing unit. The medication was not administered from the time of admission, and there was no follow-up with the pharmacy to ensure delivery. The resident experienced symptoms consistent with seizure activity, and the facility staff was unaware of the medication issues.
A resident admitted with a Stage 2 pressure ulcer experienced worsening conditions due to the facility's failure to document and manage pressure ulcer care effectively. The resident developed an unstageable pressure ulcer, with staff acknowledging ineffective treatments and lack of documentation and physician notification.
The facility failed to maintain a sanitary kitchen environment, risking food-borne illness. A dietary aide used an ineffective sanitizing solution to clean a dish cart, and the kitchen's refrigerator gaskets were unclean, with no cleaning tasks listed. The operational manager acknowledged these issues.
The facility failed to provide meaningful activities for four residents, including those with depression, dementia, rib fractures, respiratory failure, and blindness. Despite care plans indicating preferences for one-on-one activities, group engagement, and cognitive stimulation, residents were not observed participating in activities. The Activities Director acknowledged missing documentation and lack of engagement, particularly for visually impaired residents and those with anoxic brain damage.
The facility failed to ensure physician orders were reviewed and signed for four residents, risking unassessed medical needs. A resident with arthritis and heart disease had unsigned orders for several months. Another with breast cancer and diabetes lacked signed orders after April. A resident with paralysis and COPD had missing orders for multiple months, and one with diabetes and heart disease had no signed orders after June. Staff acknowledged these deficiencies.
The facility failed to ensure that residents were seen by a physician every 60 days, as required, for four residents. One resident with arthritis and heart disease had no physician visit notes for several months in 2024. Another resident with breast cancer and diabetes had no notes after April 2023. A third resident with left-sided paralysis and COPD lacked notes for June, July, and September 2024. A fourth resident with diabetes and heart disease had no notes from May 2023 through July 2024, as well as September and October 2024. The facility's Administrator and Regional Director of Clinical Services confirmed the absence of evidence for regular physician visits, placing residents at risk for unmet medical needs.
A LTC facility failed to maintain a medication error rate below 5%, resulting in an 11.36% error rate. One resident with respiratory failure did not rinse their mouth after using an inhaler, and another resident with multiple diagnoses did not receive prescribed medications due to unavailability and did not rinse after inhaler use. Staff acknowledged these errors.
The facility failed to follow infection control standards during a March 2024 outbreak, with residents experiencing vomiting and diarrhea. Staff did not confirm if it was Norovirus, and there was no follow-up testing or reporting. Additionally, a resident with acute kidney failure had their catheter tubing on the ground, contrary to care plan instructions.
The facility failed to administer bowel care and follow therapy recommendations for several residents, leading to unmet care needs. A resident with stroke and heart disease was not assisted with meals as required, and two residents did not receive timely bowel care, with one experiencing ineffective PRN care without further assessment. Another resident had inadequate documentation and assessment of wounds, with no physician notification of new open wounds.
The facility failed to provide adequate supervision and maintain a safe environment for residents, resulting in multiple deficiencies. A resident with dysphagia was left unsupervised during meals, contrary to their care plan. Another resident experienced a fall due to unlocked wheelchair brakes, with no care plan update to address this risk. Additionally, residents at risk for falls did not receive necessary neurological assessments or care plan updates after incidents, and a resident with dementia had unaddressed injuries due to inadequate pain assessment.
The facility failed to provide adequate staffing, resulting in long wait times for residents on three wings. Residents reported delays in receiving assistance, with some waiting over an hour. Staff interviews confirmed the facility was often short-staffed, with CNAs handling more residents than state requirements allow. The facility struggled to cover for absent staff, relying on agency staff who sometimes did not show up.
The facility did not maintain RN coverage for eight consecutive hours per day for 6 out of 55 days reviewed, risking unmet assessment needs. The Administrator and DNS noted difficulties in finding replacements when RNs called off.
The facility faced multiple deficiencies, including failure to manage pressure ulcer treatments, inadequate fall assessments, insufficient staffing, and lack of timely pharmaceutical services, leading to immediate jeopardy and substandard care. Additionally, significant medication errors and failure to follow infection control standards were noted.
The facility failed to address grievances for two residents regarding missing personal property. One resident reported a missing heavy jacket, and another reported a missing gold wedding ring. Despite staff efforts, neither item was found, and grievances were not resolved, placing residents at risk for unresolved issues.
A facility failed to assess the use of a scoop mattress as a physical restraint for a resident with anxiety and catatonic schizophrenia, who was at risk for falls. The resident was observed on the mattress without documentation in the care plan or clinical record assessing it as a restraint. Initially, staff believed the resident could not get out of bed independently, but later confirmed the resident could do so.
A resident with diabetes, who was cognitively intact, reported a missing wallet and money from their bank account. Despite a police report being filed by social services, the facility did not submit a Facility Reported Incident (FRI) to the State Survey Agency, failing to comply with reporting requirements and placing residents at risk for abuse.
A resident with a mental illness diagnosis was not referred for a PASARR Level II evaluation despite exhibiting behaviors such as medication refusal, agitation, and distrust towards staff. The resident's condition included high blood pressure and refusal of care, yet no referral was made, as confirmed by the Social Service Director.
A facility failed to involve a resident's POA in the care planning process despite the resident's moderate cognitive impairment and history of refusing bathing. The resident's family member, who was the POA, was not present during care plan discussions and was unaware of whom to contact for concerns. Staff acknowledged the need for POA involvement but did not act accordingly.
A resident with aphasia was not evaluated for an AAC device despite being nonverbal and relying on gestures for communication. A CNA noted the resident often confused 'no' for 'yes,' complicating care. Three speech therapy evaluations recommended a non-speech generating device, but the resident was not provided with an AAC device.
The facility failed to provide adequate respiratory care for two residents using CPAP machines. Both residents had physician orders for CPAP use and maintenance, but observations revealed improper storage and lack of cleaning of the CPAP masks. Staff confirmed the absence of a system for the care of the respiratory equipment, leading to unmet respiratory needs.
A resident with a history of trauma related to a child's death did not receive trauma-informed care when a CNA shaved their mustache against their preference, causing distress. The mustache was a significant reminder of the resident's deceased child. The facility failed to assess the resident's trauma triggers and did not provide appropriate emotional support.
A facility failed to monitor a resident on trazodone, prescribed for insomnia, despite no documented indication for its use. The resident, with dementia and a history of falls, was difficult to arouse in the morning, and staff acknowledged the lack of sleep monitoring.
A resident with diabetes and cognitive intactness was observed with a missing tooth, which a family member had reported to a CNA a month earlier. Despite a dental office contacting the family member to arrange an appointment, the facility failed to follow up and schedule the necessary dental care. Interviews with staff revealed a lack of communication and awareness regarding the resident's dental needs, resulting in the resident not receiving timely dental services.
A resident with a stroke and intestinal obstruction did not receive the prescribed Easy to Chew diet texture, receiving cubed pork instead of minced pork. The Dietary Manager confirmed the unavailability of minced pork. A Speech-Language Pathologist noted multiple residents not receiving correct diets, highlighting dietary staff's lack of understanding.
A resident with anxiety and catatonic schizophrenia, who required a non-weighted built-up spoon for meals, was observed eating with their hands and was given a regular spoon instead. A CNA confirmed the lack of access to the specialized equipment, and the Regional Director of Therapy Operations acknowledged the oversight.
A resident with anxiety and dementia experienced unmet needs due to the facility's failure to maintain cleanliness of bedside commodes. Despite a care plan indicating the need for assistance, staff interviews revealed a recurring issue with CNAs not cleaning commodes, leading to unpleasant conditions and the resident attempting to clean it themselves.
A resident with PTSD was pushed by another resident during an altercation over cigarette smoke, leading to a failure to protect the resident from mental and physical abuse. The incident, captured on security footage, left the resident upset and fearful, with abuse not ruled out by the investigation.
The facility failed to develop baseline care plans for two residents, one with diabetes and another with a fall risk. A resident readmitted with diabetes complications lacked a care plan addressing insulin management and symptoms to monitor. Another resident with a history of falls did not have fall interventions included in their care plan. Staff acknowledged these omissions.
The facility failed to assist two residents with ADLs, leading to unmet needs. One resident, with severe cognitive impairment, was left incontinent due to staff inattention, while another resident missed scheduled showers due to inadequate follow-up on refusals. Public complaints and staff interviews confirmed these deficiencies.
The facility did not complete an annual performance review for a CNA hired in May 2022. This was confirmed by the Administrator during a review of performance documentation.
The facility failed to post accurate and complete staffing information, risking incomplete and inaccurate data for residents. Observations from the Direct Care Staff Daily Reports (DCSDR) revealed missing census documentation for several shifts and unposted reports over multiple days.
Failure to Implement Adequate Fall Risk Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and implementation of fall risk interventions for a resident with known cognitive impairment, behavioral issues, and a history of falls. The resident was admitted with dementia, anxiety, and a recent fractured thigh bone, and assessments documented that the resident was at risk for wandering, had multiple prior falls, poor safety awareness, dizziness, communication problems, incontinence, and behaviors such as frustration, aggression, and ambulating without assistance into others’ rooms. The care plan identified the resident as at risk for falls due to a recent fracture and balance problems, and specified the need for one staff to assist with transfers and non‑pharmaceutical interventions such as not forcing or rushing care and providing one‑on‑one and decreased overstimulation as needed. Behavior documentation in early January showed episodes of agitation, threats toward others, pacing without staff assistance, and unsuccessful interventions to address these behaviors. On the day of the incident, the resident experienced two falls. In the first, the resident was last seen in bed, then stood up and held the windowsill without assistance before falling onto a floor mat and hitting an elbow; staff reported that during that shift the resident required a second staff member for transfer safety due to increased behaviors and lack of balance, but only one staff member was available, and there were no available staff to provide one‑on‑one supervision despite the resident’s continued attempts to self‑transfer. Later that day, the resident was found sitting on the floor near the bed after an unwitnessed fall and stated having hit the head; no injuries were initially noted, but the resident was sent to the hospital for evaluation. Hospital records documented admission following a fall with head trauma and critical subdural hematomas, after which the resident remained unresponsive and was transitioned to palliative care. Facility staff, including the unit manager and DNS, acknowledged that one‑on‑one supervision was needed for this resident after the first fall and that the scheduling coordinator was unavailable to find staff to provide it.
Malfunctioning Call Light System Affecting Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that resident call lights functioned properly and independently in resident rooms and bathrooms. For one resident admitted in January 2021 with pain, a CNA tested the call light and found that when this resident’s call light was turned off, the roommate’s call light also turned off. Similar testing was done for two other residents, one admitted in January 2024 with stroke and diabetes and another admitted in January 2023 with heart disease, and in both cases, when each resident’s call light was turned off, the roommate’s call light also turned off. The facility administrator confirmed that the call lights should operate independently. Another resident, admitted in June 2024 with pain and repeated falls and documented as cognitively intact on a quarterly MDS, reported that it took staff about 20 minutes to answer call lights and believed the call light was malfunctioning because it would shut off by itself. This resident stated that these concerns had been reported to staff without follow-up. A CNA acknowledged that the resident had reported multiple times that the call light was not working but initially believed the resident was mistaken. Upon testing, the CNA confirmed the call light was not functioning properly and that turning off this resident’s call light also turned off the roommate’s call light.
Improper Maintenance of Water Dispenser and Unlabeled Beverages in Resident Snack Refrigerator
Penalty
Summary
The facility failed to ensure that a hallway water dispenser was maintained and sanitized in accordance with professional standards. A public complaint was received alleging that filtered water stations had pink slime and were not replaced or cleaned. During observation, the water dispenser across from the main nurses' station was found with an orangish buildup on the cold-water outlet and a gray to black buildup on the hot-water outlet. An LPN confirmed the buildup on both outlets. The housekeeping manager stated that housekeeping was responsible only for cleaning and sanitizing the outside of the dispenser, not the outlets or the inside. The maintenance director reported there was no cleaning schedule or documentation showing that the water dispenser outlets were regularly cleaned. The administrator stated he expected staff to complete the necessary activities for their job as required. The facility also failed to ensure that drinks stored in a resident snack refrigerator were labeled in accordance with professional standards. During observation, three clear pitchers containing red and yellow liquids were found in the resident snack refrigerator without any labels indicating when they were placed there or when they should be removed. The LPN confirmed the pitchers were not labeled. The dietary manager confirmed that the pitchers of juice in the resident snack refrigerator should have date labels. The administrator again stated he expected staff to complete the necessary activities for their job as required.
Failure to Inform Resident of Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to inform a resident about the side effects of psychotropic medications prior to administration. The resident, who was admitted with a diagnosis of seizures, was prescribed and administered several psychotropic medications, including asenapine, buspirone, lamotrigine, and aripiprazole (Abilify), between February and June 2025. Record review and staff interviews confirmed there was no documented evidence that the resident was informed about the side effects of these medications before they were given. Facility staff, including the Social Services Director, Administrator, Director of Nursing Services, and Regional Nurse, acknowledged that the resident had not been informed, and no additional information was provided to demonstrate compliance.
Failure to Protect Resident from Sexual Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident was not protected from sexual abuse by another resident. The incident involved two cognitively intact residents, one with diabetes and a below-the-knee amputation, and the other with a cognitive communication deficit. During a group activity, one resident made a joke about touching all the doughnuts, after which the other resident took a doughnut, wiped it in their crotch area, ate it, and made a comment implying they had now touched all the doughnuts. Multiple staff and witnesses confirmed the incident, with one staff member observing the affected resident become visibly upset and quiet immediately afterward. Following the incident, the affected resident reported feeling triggered by the presence of the other resident for at least a week and actively avoided them. Staff interviews indicated that the resident was angry and not acting like themselves for about a week after the event. The incident was corroborated by several staff members, including the activities director and CNAs, who noted the resident's emotional distress and confirmed that an unwanted sexual incident had occurred.
Insufficient Nursing Staff Resulting in Missed Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the care needs of all residents, resulting in missed and delayed incontinent care and resident showers for six sampled residents. Resident Council notes from January and March 2025 documented ongoing concerns about short staffing and unmet care needs, including missed scheduled showers. Review of shower records and staff documentation showed that multiple residents did not receive their scheduled showers, with reasons cited such as environmental limitations, refusals, or marked as not applicable. One resident's records indicated missed showers on two separate occasions. Interviews with residents and staff confirmed that staffing shortages were persistent, leading to untimely responses to call lights, missed showers, and delayed incontinent care. Several CNAs and licensed nurses reported being unable to meet care plan needs, with some residents found soaked in urine and not assisted out of bed. Staff consistently described the staffing situation as inadequate and chaotic, and facility leadership acknowledged the shortfall in CNA staffing and the resulting missed care for the identified residents.
Inadequate Wound Care and Monitoring for Three Residents
Penalty
Summary
The facility failed to provide adequate wound care for three residents, leading to potential risks of worsening wounds and infections. Resident 101, admitted with second-degree burns on both feet, did not receive timely wound care as per hospital discharge orders. The facility did not initiate the prescribed wound care until two days after admission, and there was no documentation of wound care for several days. This resulted in the resident developing an infection, requiring hospital readmission and debridement. Resident 102, admitted with a fractured right femur, did not have their surgical site monitored for signs of infection until 23 days after admission. The care plan was not updated to include necessary monitoring until much later, and weekly skin evaluations were not completed. This lack of timely monitoring and care could have led to complications in the resident's recovery process. Resident 103, with a surgical site on the hip, also experienced delayed monitoring for signs of infection. The order to monitor the surgical site was not implemented until nine days after admission. The facility staff acknowledged the delay in monitoring and attributed it to issues with receiving wound care instructions from hospitals, which contributed to the deficiency in care provided to these residents.
Failure to Prevent Falls for Cognitively Impaired Resident
Penalty
Summary
The facility failed to adequately assess and implement effective interventions to prevent falls for a resident with severe cognitive impairment and a history of repeated falls. The resident, who had a BIMS score of 5 indicating severe cognitive impairment, experienced 27 falls over a two-month period. The care plan for the resident included interventions such as frequent rounding, keeping the call light within reach, and staff-provided care. However, there was no documented evidence that the facility conducted an analysis of the falls to evaluate the effectiveness of these interventions. Additionally, some interventions listed in the incident reports were not part of the resident's care plan, indicating a lack of consistency and thoroughness in the implementation of fall prevention strategies. Interviews with staff and family members revealed concerns about inadequate staffing levels and the effectiveness of the fall interventions in place. Staff members reported that the resident required one-to-one care due to frequent falls and sundowning behaviors, but the facility did not have sufficient staff to provide this level of care. The facility administrator acknowledged that the care plan was followed for some falls but could not explain why the resident experienced so many falls or why there was no assessment of the interventions' effectiveness. The lack of adequate supervision and failure to reassess and adjust the care plan placed the resident at risk for recurring falls and subsequent injuries.
Inappropriate Antibiotic Administration for Residents
Penalty
Summary
The facility failed to ensure appropriate antibiotic administration for three residents, leading to significant health concerns. Resident 242, who had a history of dementia, was not given the correct antibiotic therapy for multiple UTIs, resulting in hospitalization. Despite a urinalysis indicating an infection and a culture showing resistance to the prescribed antibiotic, Cipro, the resident continued to receive ineffective treatment. This oversight contributed to the resident's decline, leading to hospice care and eventual death. Resident 29, admitted with a history of stroke and UTI, was found on the floor and transported to the ER, where a urine culture was initiated but not completed. Despite the absence of culture results, the resident was prescribed Keflex, which was later deemed ineffective. The provider did not respond to the antibiotic time-out assessment, and the resident completed the antibiotic course without appropriate documentation or adjustment based on culture results. Resident 30, with a history of stroke and chronic kidney disease, was prescribed amoxicillin-Pot clavulanate for a UTI caused by MDR Klebsiella pneumoniae, despite the organism's resistance to amoxicillin. The prescription was not aligned with the culture results, indicating a lack of appropriate antibiotic selection. These deficiencies highlight the facility's failure to ensure residents received effective antibiotic treatments based on culture and sensitivity reports.
Removal Plan
- Residents in the facility would be assessed for UTI symptoms and those assessed to have UTI symptoms would be placed on alert charting and the provider notified for recommendations.
- Review of residents who were treated for a UTI to ensure the residents' UTIs were treated with an appropriate antibiotic based on the Culture and Sensitivity Reports. The provider would be contacted regarding any changes in antibiotic therapy as indicated.
- Residents in the facility on hospice services or on comfort measures would have Physician Orders for Life Sustaining Treatment (POLST) forms reviewed regarding their wishes for treatment, including antibiotics, to ensure the information on the POLST form remained accurate to the residents' current wishes.
- Licensed Nurses would be educated on follow-up required for residents who complain of symptoms consistent with a UTI including provider notification. Daily morning clinical review process would be updated to include a review of any urinalysis tests completed to be followed up daily until the Culture and Sensitivity report was available to ensure antibiotics ordered were appropriate. Providers would be notified of the Culture and Sensitivity results as well as what antibiotics residents were currently administered if applicable.
- Staff education would be completed on reporting resident complaints or potential changes in condition to the charge nurse for follow up.
- Nurse managers would be educated on the need to review a resident's POLST wishes related to antibiotic treatment as indicated for residents on hospice or comfort services if an infection developed.
- The DNS or designee would audit residents treated for UTIs to ensure the Culture and Sensitivity reports were reviewed and followed up on as they became available, and the appropriate follow-up was done if the ordered antibiotic was not effective.
- The consultant pharmacist would review antibiotic use for UTIs and the accompanying Culture and Sensitivity results to ensure appropriate antibiotics were prescribed. Findings would be reported to the QAPI Committee and Medical Director. Reviews would continue ongoing if indicated.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to provide timely pharmaceutical services for three residents, leading to significant medication administration issues. Resident 198, who was admitted with a history of seizures, did not receive their prescribed antiseizure medication, lacosamide, from 10/11/24 to 10/21/24. The medication was consistently unavailable, and there was no documentation of follow-up with the pharmacy or physician to resolve the issue. This lack of medication placed Resident 198 at risk for seizures, as they reported feeling shaky and experiencing symptoms indicative of seizure activity. Resident 21, admitted with high blood pressure and lung disease, missed doses of Atorvastatin from 10/1/24 to 10/3/24 due to the medication being unavailable. There was no documentation indicating that the physician or pharmacy was notified about the missed doses. Similarly, Resident 78, who had respiratory failure, missed doses of dexamethasone and Advair inhaler due to unavailability, with no follow-up or notification to the physician or pharmacy documented. Additionally, the facility failed to ensure proper narcotic medication management. During a review of narcotic reconciliation records, it was found that many signature areas were left blank, indicating that staff did not consistently sign the narcotic reconciliation book at every shift change as required. This lack of adherence to protocol further highlights the facility's deficiencies in medication management and documentation.
Removal Plan
- Resident 198's provider was notified of the medication error of missed lacosamide dose, and symptoms the resident reported.
- Lacosaminde was initiated.
- A medication error incident rate report was completed and an investigation initiated.
- Resident 198 was placed on alert charting to monitor for effectiveness of lacosamide and resolution or symptoms reported by the resident.
- Other residents in the facility with orders for antiseizure medications were to be reviewed to validate their medication was available in the facility and being administered as ordered.
- Resident admitted to the facility were to be reviewed to validate that medications ordered were available in the facility and being administered as ordered.
- Findings of the above audits will be reviewed with the medical director and the facility consultant pharmacist to review for recommendations.
- Licensed nurses and CMAs were to be educated on requirements related to ensuring medications for new admissions were delivered and available for administration, and the steps to take were when a medication was not delivered or available, including steps related to medications that required a prescription for pharmacy dispensation.
- The facility admission process was updated to include a review of medications ordered by the hospital to identify any medications that required a prescription to be filled by the pharmacy. Admissions staff would communicate with the hospital to ensure that prescriptions were sent with the resident and/or sent directly to the pharmacy.
- Morning clinical review processes were updated to include a review of admissions from the prior day to ensure medications were available in the facility. Prescriptions noted as not yet on-hand would receive follow-up by nursing to include calling the pharmacy to inquire about the status of the medication, notification of the status to be communicated to the provider, appropriate documentation as evidence of the follow-up actions. Additionally a review of a report of medications not administered would occur to identify any medications not administered due to availability issues.
- Audits would be done to ensure prescription medications were available in the facility and administered as ordered. Audits results would be reported to QAPI Committee and ongoing as indicated.
Failure to Administer Antiseizure Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of antiseizure medication. The resident, who was admitted with a history of seizures, did not receive their prescribed lacosamide medication from the time of admission. The medication was supposed to be administered twice daily starting from the admission date, but it was consistently unavailable in the facility's automated electronic medication dispensing unit. Throughout the period from admission to the date of the survey, the medication was repeatedly noted as unavailable, and there was no documentation indicating that the facility contacted the pharmacy to follow up on the medication's delivery. The resident reported feeling shaky and experiencing symptoms consistent with seizure activity, such as an electrical current sensation and daily headaches, due to the lack of medication. The facility's staff, including the Director of Nursing Services, was unaware of the issues with the resident's admission medications. The process required the admission nurse to notify the pharmacy if a medication was not delivered, with follow-up expected on every shift until the medication arrived. However, this process was not followed, leading to the resident being at risk for increased seizure activity due to the lack of timely pharmaceutical services.
Removal Plan
- Resident 198's provider was notified of the medication error of missed lacosamide doses, and symptoms resident reported.
- Lacosamide was initiated.
- A medication error incident rate report was completed and an investigation initiated.
- Resident 198 was placed on alert charting to monitor for effectiveness of lacosamide and resolution or symptoms reported by the resident.
- Other residents in the facility with orders for antiseizure medications were to be reviewed to validate their medication was available in the facility and being administered as ordered.
- Resident admitted to the facility were to be reviewed to validate that medications ordered were available in the facility and being administered as ordered.
- Findings of the above audits will be reviewed with the medical director and the facility consultant pharmacist to review for recommendations.
- Licensed nurses and CMAs were to be educated on requirements related to ensuring medications for new admissions were delivered and available for administration, and the steps to take were when a medication was not delivered or available, including steps related to medications that required a prescription for pharmacy dispensation.
- The facility admission process was updated to include a review of medications ordered by the hospital to identify any medications that required a prescription to be filled by the pharmacy. Admissions staff would communicate with the hospital to ensure that prescriptions were sent with the resident and/or sent directly to the pharmacy.
- Morning clinical review processes were updated to include a review of admissions from the prior day to ensure medications were available in the facility. Prescriptions noted as not yet on-hand would receive follow-up by nursing to include calling the pharmacy to inquire about the status of the medication, notification of the status to be communicated to the provider, appropriate documentation as evidence of the follow-up actions. Additionally a review of a report of medications not administered would occur to identify any medications not administered due to availability issues.
- Audits would be done to ensure prescription medications were available in the facility and administered as ordered. Audits results would be reported to QAPI Committee and ongoing as indicated.
Failure to Manage Pressure Ulcer Care
Penalty
Summary
The facility failed to accurately assess, care plan, implement, follow, and maintain pressure ulcer treatments and care plans for a resident who was admitted with a Stage 2 pressure ulcer on the coccyx. The resident, who had diagnoses including kidney failure and was at risk for pressure ulcers due to incontinence and decreased mobility, was admitted with a Stage 2 pressure ulcer. However, the facility did not document the location of the wound in the initial Skin and Wound Evaluation, and the wound was later found to have slough, indicating it had become an unstageable pressure ulcer. The facility also failed to document new wounds and worsening conditions. A new open area on the resident's right buttocks was noted, but no Skin and Wound Evaluation or incident report was documented. The resident's condition worsened, with the wound becoming open, dark red, moist, and surrounded by purple bruising, yet there was no documentation or notification to the physician. Staff acknowledged that the treatments were ineffective, documentation was lacking, and the physician was not informed of the worsening condition, which contributed to the development of an avoidable unstageable pressure ulcer.
Sanitation Deficiency in Kitchen and Refrigerator Maintenance
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment, which placed residents at risk for food-borne illness. During an observation, a dietary aide was seen using a rag from a sanitizing solution bucket to clean a soiled dish cart. The solution was found to be ineffective, with a concentration of only 100 PPM, below the required range of 150-400 PPM. The aide admitted that the sanitizer was changed every four hours, but the presence of black flecks in the solution indicated it was not clean or effective. The operational manager acknowledged the inadequacy of the system in place to ensure the sanitizer's effectiveness. Additionally, the facility's kitchen and snack area refrigerators were not properly cleaned. Black specks were observed on the gaskets of the walk-in refrigerator doors, and the cleaning list did not include tasks for refrigerator maintenance. The resident snack refrigerator had a torn gasket with dried brown particles in its creases and on the top shelf. The operational manager confirmed that the refrigerators were not cleaned and recognized the need to add this task to the cleaning list to ensure compliance.
Failure to Provide Meaningful Activities for Residents
Penalty
Summary
The facility failed to provide meaningful activity programs for four residents, leading to a deficiency in meeting their needs for engagement and social interaction. Resident 14, who was admitted with depression and dementia, had a care plan indicating a desire for one-on-one activities, but there was no documentation of her preferred activities or reasons for lack of involvement. Observations showed that Resident 14 was not engaged in activities, and the Activities Director admitted to missing documentation in the care plan. Resident 48, admitted with rib fractures and respiratory failure, was not observed participating in activities during multiple observations. Despite expressing a preference for group activities and going outside, Resident 48 reported that staff did not facilitate her participation, especially on weekends. The Activities Director acknowledged not having spoken to Resident 48 about her activity preferences since her admission. Resident 52, who is blind and at risk for social isolation, was not assessed for activity preferences upon admission. Although she expressed interest in audio books and music, these were not provided. Observations showed limited participation in activities, and the Activities staff admitted to lacking experience with visually impaired residents. Similarly, Resident 68, with anoxic brain damage, was not offered activities despite a care plan indicating a need for cognitive stimulation. The Activities Director confirmed the lack of engagement for Resident 68.
Failure to Ensure Physician Orders Reviewed and Signed
Penalty
Summary
The facility failed to ensure that physician orders were reviewed and signed by a physician for four sampled residents, which placed them at risk for unassessed medical needs and adverse side effects of medication. Resident 2, admitted in September 2021 with arthritis and heart disease, had no signed physician orders for several months spanning from January 2023 to June 2024. Staff acknowledged the absence of signed orders during a review of the resident's clinical record. Similarly, Resident 29, admitted in January 2024 with breast cancer and diabetes, had no signed physician orders after April 2023. Resident 31, admitted in August 2018 with left-sided paralysis and COPD, lacked signed physician orders for multiple months between August 2023 and October 2024. Resident 35, admitted in November 2023 with diabetes and heart disease, also had no signed physician orders after June 2023. The facility's administrator and regional director of clinical services confirmed the absence of signed orders for these residents.
Failure to Ensure Regular Physician Visits for Residents
Penalty
Summary
The facility failed to ensure that residents were seen by a physician every 60 days, as required, for four sampled residents. Resident 2, admitted in September 2021 with arthritis and heart disease, had no physician visit notes for several months in 2024, including January through March, May, June, and August. Resident 29, admitted in January 2024 with breast cancer and diabetes, had no physician visit notes after April 2023. Resident 31, admitted in August 2018 with left-sided paralysis and COPD, lacked physician visit notes for June, July, and September 2024. Resident 35, admitted in November 2023 with diabetes and heart disease, had no physician visit notes from May 2023 through July 2024, as well as September and October 2024. During an interview on October 28, 2024, at 4:00 PM, the facility's Administrator and the Regional Director of Clinical Services confirmed that no further physician visit notes were available for these residents. They acknowledged the absence of evidence indicating that the residents had been seen by a physician every 60 days, as required. This deficiency placed the residents at risk for unmet medical needs.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5 percent, resulting in an 11.36 percent error rate. This was identified through five errors out of 44 medication administration opportunities. One incident involved a resident admitted with respiratory failure who was prescribed Advair powder inhaler. The resident inhaled the medication twice without rinsing their mouth afterward, contrary to the physician's order. Staff acknowledged the error, noting that the resident should have rinsed their mouth to prevent mouth infections. Another incident involved a resident with heart failure, lung disease, and anorexia. The resident was prescribed Combivent and Incruse Ellipta inhalers, along with iron oral solution and metoprolol. The resident did not rinse their mouth after using the inhalers, and there was a failure to administer the iron oral solution and metoprolol due to unavailability. Staff admitted to not following the proper procedure for mouth rinsing and acknowledged the medication unavailability, which was not communicated to the Director of Nursing Services.
Infection Control Deficiencies During Outbreak and Catheter Care
Penalty
Summary
The facility failed to adhere to infection control standards during an outbreak of illness in March 2024, which was characterized by residents experiencing vomiting and diarrhea across all halls. Despite the widespread nature of the outbreak, staff did not confirm whether the illness was Norovirus, and there was a lack of follow-up testing due to the wrong specimen containers being sent. Staff members, including a Registered Nurse and the Director of Nursing Services, acknowledged the outbreak but did not report it, and there was no verification of the illness being Norovirus. Additionally, the facility did not maintain proper infection control practices for a resident with an indwelling catheter. The care plan for the resident, who was admitted with acute kidney failure, required that the catheter collection bag be kept off the floor. However, an observation on October 22, 2024, revealed that the catheter tubing was on the ground, which was acknowledged by the Wound Nurse as not meeting the expected standard of care.
Failure to Administer Bowel Care and Follow Therapy Recommendations
Penalty
Summary
The facility failed to administer bowel care and follow therapy recommendations for several residents, leading to unmet care needs. Resident 8, admitted with diagnoses including stroke and heart disease, required extensive assistance for eating and was to be seated upright in a wheelchair during meals. However, observations revealed that Resident 8 was left in bed in a slouched position with meals unattended, contrary to therapy recommendations and care plan interventions. Staff interviews confirmed the lack of communication and adherence to the care plan, resulting in Resident 8 not receiving the necessary assistance and positioning during meals. Additionally, the facility did not provide timely bowel care for Residents 30 and 70, who experienced extended periods without bowel movements. Despite the care plan requiring bowel care every 24 hours and physician notification after four days without a bowel movement, Resident 30 did not receive care until the fifth day, and Resident 70's PRN bowel care was ineffective without further assessment or physician notification. Furthermore, Resident 191, admitted with a pressure ulcer and genital wounds, had inadequate documentation and assessment of the wounds, with no physician notification of new open wounds. These deficiencies highlight a failure in following care plans and ensuring proper documentation and communication regarding resident care needs.
Inadequate Supervision and Care Plan Updates Lead to Multiple Deficiencies
Penalty
Summary
The facility failed to ensure adequate supervision and environmental safety for several residents, leading to multiple deficiencies. Resident 14, diagnosed with dysphagia, was observed eating unsupervised despite care plan requirements for supervision during meals due to swallowing difficulties. Staff inconsistencies in understanding and implementing the care plan were evident, as some staff believed supervision meant frequent checks rather than continuous presence during meals. Resident 52, who is blind and at risk for falls, experienced an unwitnessed fall due to unlocked wheelchair brakes. Despite a care plan indicating the need for a safe environment and proper use of mobility aids, there was no documentation ensuring wheelchair brakes were locked. Staff failed to update the care plan to address this specific risk, and the resident's fall was not thoroughly investigated or documented. Resident 70, at risk for falls due to confusion and balance issues, experienced two unwitnessed falls without appropriate neurological assessments or care plan updates. Similarly, Resident 85, with dementia and orthostatic hypotension, had a care plan lacking specific interventions for her condition, such as routine checks. Resident 292, with a history of falls and severe cognitive impairment, had multiple unwitnessed falls without effective interventions or care plan updates. The facility did not conduct necessary skin assessments or alternative pain assessments, leading to unaddressed injuries.
Staffing Deficiency Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of residents on three of four halls, specifically the A, B, and G wings. This deficiency was highlighted by a public complaint received in April 2024, which reported that call light wait times frequently exceeded 30 minutes. Interviews conducted on October 21, 2024, with several residents revealed that they experienced long wait times for assistance, with some residents waiting up to an hour or more. Residents expressed frustration over the delays, which affected their ability to perform daily activities and receive timely care. One resident mentioned that the frequent change in staff led to a lack of familiarity with residents' needs, contributing to the delays. Staff interviews further corroborated the issue of insufficient staffing. A CNA reported being assigned 10 to 14 residents per shift, which hindered her ability to respond to call lights and complete necessary tasks such as resident showers and meal assistance. Another CNA noted that she often had more residents than state staffing requirements allowed, forcing her to start tasks early and stay late. A staff witness confirmed that the facility lacked an effective system to cover for absent staff, leading to situations where only one nurse was available for the entire facility during the day shift. The facility's administrator and DNS acknowledged the reliance on agency staff, who sometimes failed to show up, exacerbating the staffing shortages.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to staff a registered nurse (RN) for eight consecutive hours per day, seven days a week, for 6 out of 55 days reviewed. This deficiency was identified through a review of the Direct Care Staff Daily Reports covering specific periods in April, September, and October 2024. The absence of RN coverage for the required duration placed residents at risk for unmet assessment needs. During an interview on October 29, 2024, the Administrator and the Director of Nursing Services (DNS) acknowledged that RN call-offs occurred, and finding replacements was challenging.
Multiple Deficiencies Lead to Immediate Jeopardy and Substandard Care
Penalty
Summary
The facility was found to have multiple deficiencies that resulted in immediate jeopardy and substandard quality of care. These included failures in implementing and maintaining pressure ulcer treatments for a resident, leading to a worsening condition. Additionally, the facility did not adequately assess residents after falls or maintain an environment free from accident hazards for several residents. There was also a failure to provide sufficient RN and CNA staffing to meet resident needs, and residents were not consistently seen by physicians, nor were physician orders reviewed and signed as required. Further deficiencies were noted in the provision of timely pharmaceutical services, which constituted an immediate jeopardy situation for some residents. Significant medication errors were identified, also leading to immediate jeopardy and substandard care. Infection control standards were not followed for a resident and across four halls. Lastly, the facility failed to ensure appropriate antibiotics were administered for UTIs in several residents, which was another immediate jeopardy situation.
Failure to Address Resident Grievances on Missing Personal Property
Penalty
Summary
The facility failed to address grievances related to personal property for two residents. Resident 52, who was admitted with a diagnosis of diabetes and was cognitively intact, reported a missing heavy jacket on a grievance report dated July 3, 2024. Despite staff efforts to locate the jacket in the laundry, it was not found, and there was no resolution to the grievance. Interviews with Resident 52 and staff confirmed the lack of follow-up and resolution for the missing jacket, which held sentimental value for the resident. Resident 70, admitted with a diagnosis of pneumonia, reported a missing gold wedding ring, as noted in a progress note dated October 4, 2024. The resident's inventory list included the gold ring, but staff did not locate it, and no grievance was filed. The Director of Nursing Services acknowledged the missing ring and the absence of a grievance, indicating a failure to address the resident's concern. This lack of action placed both residents at risk for unresolved grievances regarding their personal property.
Failure to Assess Physical Restraint Use
Penalty
Summary
The facility failed to assess the use of a physical restraint for a resident reviewed for physical restraints, placing residents at risk for potential abuse or neglect. The facility's policy indicated that a concave mattress could be considered a physical restraint if it prevents a resident from independently getting out of bed. A resident admitted in March 2024 with diagnoses including anxiety and catatonic schizophrenia was observed on a scoop mattress, which was not documented in the care plan as a restraint. Despite the resident's fall risk, there was no documentation in the clinical record assessing the mattress as a restraint. Staff initially stated the resident could not get out of bed independently, but later confirmed with therapy that the resident could indeed get out of bed on their own.
Failure to Report Misappropriation of Resident's Property
Penalty
Summary
The facility failed to report a case of misappropriation to the State Survey Agency involving a resident who was cognitively intact and admitted with a diagnosis of diabetes. The resident reported a missing wallet and money from their bank account, which was documented in a grievance report. Although a police report was filed by social services on behalf of the resident, the facility did not submit a Facility Reported Incident (FRI) as required. This oversight placed residents at risk for abuse.
Failure to Refer Resident for PASARR Level II Evaluation
Penalty
Summary
The facility failed to ensure a resident was referred to the state agency authority for a Level II PASARR evaluation, which is necessary for individuals with serious mental illness. This deficiency was identified for a resident who was admitted to the facility with a mental illness diagnosis. Despite the resident's refusal of medications, care, and blood pressure monitoring, and exhibiting behaviors such as agitation and distrust towards staff, no PASARR Level II assessment was requested. The resident's medical records did not indicate any such referral, even though the resident's condition and behaviors warranted it. The resident, who was admitted in September 2023, showed signs of social isolation and depression, and a plan was made to refer them to behavioral health services. However, over the following months, the resident increasingly refused medications and care, exhibited high blood pressure, and expressed distrust towards staff, believing they were administering unnecessary medications. Despite these ongoing issues, the facility did not initiate a PASARR Level II evaluation, as confirmed by the Social Service Director, who stated that such a request was not made for the resident.
Failure to Involve POA in Care Planning
Penalty
Summary
The facility failed to involve residents and/or their representatives in the care planning process, specifically for one resident who was admitted with a diagnosis of stroke and was moderately cognitively impaired. The resident, identified as Resident 8, was admitted in September 2024 and had a history of refusing or not receiving bathing on multiple occasions. Despite being present at a care plan conference, the resident's family member, who was also the Power of Attorney (POA) for care, was not involved in the care planning process. The family member expressed a desire to be involved due to the resident's memory issues and was unaware of whom to contact regarding concerns. Staff acknowledged the importance of involving the POA but failed to do so, leading to a deficiency in the care planning process.
Failure to Provide AAC Device for Nonverbal Resident
Penalty
Summary
The facility failed to evaluate a resident for an augmentative and alternative communication device (AAC) despite the resident's severe communication impairment due to aphasia. The resident, who was admitted with a diagnosis of aphasia, was observed to be nonverbal and relied on pointing and gestures for communication. During an interview, a CNA reported that the resident often confused 'no' for 'yes,' complicating the staff's ability to meet the resident's communication and care needs. It was confirmed by the speech therapist and clinical supervisor that three speech therapy evaluations were conducted, which identified the resident's primary mode of communication as nonverbal and recommended a non-speech generating device. However, the resident was not evaluated for an AAC device as recommended, nor was one provided in the facility.
Failure to Provide Adequate Respiratory Care for Residents
Penalty
Summary
The facility failed to provide adequate respiratory care and services for two residents who required the use of CPAP machines. Resident 21, admitted with a diagnosis of respiratory failure, had a physician's order for CPAP use at bedtime and specific instructions for cleaning the CPAP mask and maintaining the humidifier. However, observations over several days revealed that the CPAP mask was improperly stored in an unsanitary manner, and there was no documentation in the resident's medical record regarding the cleaning or maintenance of the CPAP equipment. Staff confirmed the lack of a system for the care of the resident's respiratory equipment. Similarly, Resident 48, also admitted with respiratory failure, had a physician's order for CPAP use and maintenance. Observations showed that the CPAP mask was not stored properly, and the resident reported that staff did not clean the mask or store it in a manner to keep it clean. Staff confirmed the unsanitary storage of the CPAP mask. These deficiencies indicate a failure to meet the respiratory needs of the residents, as there was no system in place to ensure the proper care and maintenance of the CPAP equipment.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to provide trauma-informed care to a resident with a history of mental health illness and trauma related to the death of a child. The resident, who was cognitively intact, had previously reported nightmares about the incident. During a shower, a CNA offered to shave the resident's beard and trim their hair, to which the resident agreed. However, the CNA began shaving the resident's mustache, and despite the resident's request to stop, the mustache was shaved. This action upset the resident, as the mustache held sentimental value, reminding them of their deceased child who used to play with it. The facility's social service director acknowledged that the former social services staff did not complete an assessment to identify the resident's trauma triggers or determine how staff should monitor the resident for negative outcomes. The director was unsure why the staff did not recognize the resident's trauma related to the child's death, despite the resident reporting nightmares. This oversight placed the resident at risk for re-traumatization, as their specific emotional needs were not adequately addressed by the facility.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to monitor a resident on a psychotropic medication, specifically trazodone, which was prescribed for insomnia. Resident 85, who was admitted with diagnoses of dementia and depression, was noted to be severely cognitively impaired and had a history of multiple falls. Despite a physician's order to administer trazodone at bedtime, there was no documented indication for its use, nor was there any monitoring of the resident's sleep patterns. Staff interviews revealed that the resident was difficult to arouse in the morning, and it was acknowledged that there should have been a monitoring system in place, especially given the resident's fall history and the use of trazodone for sleep.
Failure to Provide Dental Services for a Resident
Penalty
Summary
The facility failed to provide necessary dental services for a resident, identified as Resident 30, who was admitted with a diagnosis of diabetes and was cognitively intact. During an observation, it was noted that Resident 30 had a missing left upper tooth, and the resident reported that a family member, Witness 6, had noticed the broken tooth about a month prior. Witness 6 informed a CNA about the issue and later received a call from a dental office to set up an appointment for the resident. However, Witness 6 instructed the dental office to coordinate with the facility for the appointment and transportation, but did not receive any further communication from the facility regarding the dental appointment. Staff interviews revealed a lack of awareness and communication regarding the resident's dental needs. Staff 10, an LPN Unit Manager, stated he was not informed about the broken tooth, while Staff 50, an Agency CNA, mentioned that she did not pay much attention to missing teeth among residents. Additionally, Staff 27, the Social Service Director, who generally scheduled dental appointments, was unaware of the resident's need for a dental appointment. This lack of coordination and communication resulted in the resident not receiving timely dental care, placing them at risk for dental pain.
Failure to Provide Modified Textured Diets
Penalty
Summary
The facility failed to provide modified textured diets as ordered for a resident, placing them at risk for medical complications and aspiration. Resident 8, who was admitted with diagnoses including stroke and intestinal obstruction, required an Easy to Chew diet texture. However, during a lunch observation, the resident received one-inch cubed pieces of cooked pork without gravy, contrary to the prescribed minced pork with brown gravy. The Dietary Manager and Dietary District Manager confirmed that minced pork was not available for service. Additionally, a Speech-Language Pathologist observed multiple residents not receiving the correct modified textured diets, including a dessert that posed a choking hazard due to its size. This indicates a lack of understanding among dietary staff regarding modified texture diets.
Failure to Provide Assistive Eating Devices
Penalty
Summary
The facility failed to provide assistive devices for a resident with a nutritional problem who required assistance with food and fluids. The resident, admitted with diagnoses including anxiety and catatonic schizophrenia, was care planned to receive a non-weighted built-up spoon with each meal. However, observations revealed that the resident was eating with their hands during breakfast and was provided with a regular spoon instead of the specialized one during another meal. A CNA confirmed that they did not have access to the resident's specialized equipment, and the kitchen did not provide the required non-weighted built-up spoon. The Regional Director of Therapy Operations confirmed that the staff should have provided the specialized spoon as per the care plan.
Failure to Maintain Cleanliness of Bedside Commodes
Penalty
Summary
The facility failed to accommodate the needs of a resident, identified as Resident 242, who was admitted with diagnoses including anxiety and dementia. The resident's care plan, revised in February 2024, indicated a self-care performance deficit and required occasional assistance with toileting. However, a complaint received in April 2024 revealed that the resident's bedside commode was not being emptied or cleaned, leading the resident to attempt the task independently. This issue was confirmed by a witness and further supported by staff interviews. Staff members, including a CNA and housekeeping staff, acknowledged that there was a recurring problem with CNAs not cleaning bedside commodes and toilet risers in a timely manner. The housekeeping staff reported instances where meal trays were delivered to residents while their bedside commodes remained uncleaned, resulting in unpleasant odors. The facility administrator stated that the expectation was for staff to clean the bedside commode during rounds or immediately after assisting a resident, but this was not consistently followed.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from mental and physical abuse, as evidenced by an incident involving two residents. Resident 291, who was admitted with PTSD and respiratory failure, was involved in an altercation with Resident 53. Resident 53, who had a history of stroke and muscle weakness, approached Resident 291 outside and complained about cigarette smoke affecting their time in the activity room. Security footage showed Resident 53 placing a hand on Resident 291's shoulder and pushing them, although Resident 291 sustained no physical injuries. The incident was reported to the State Survey Agency, and the investigation concluded that abuse could not be ruled out. Resident 291 expressed feeling drastically upset and fearful of Resident 53 following the incident. Staff interviews revealed that Resident 291 was often outside due to being triggered by closed spaces and continued their normal activities post-incident, albeit with concerns about causing problems in the facility. The facility's failure to prevent this altercation placed residents at risk for abuse.
Failure to Develop Baseline Care Plans for Residents
Penalty
Summary
The facility failed to ensure baseline care plans were developed for two residents, leading to a risk of unmet needs. Resident 24 was readmitted with a diagnosis of type 1 diabetes and a history of diabetic ketoacidosis, yet the baseline care plan did not include information on diabetes management, insulin orders, or symptoms to monitor for high and low blood sugar levels. Staff acknowledged the absence of a baseline care plan addressing these critical aspects of Resident 24's care. Resident 243 was admitted with altered mental status and a lower back fracture, with a history of recurrent falls. However, the baseline care plan did not address the resident's fall risk or include fall interventions. Staff confirmed that fall interventions were expected to be part of the baseline care plan but were not included.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents, leading to unmet needs. Resident 31, who was admitted with diagnoses including stroke and dementia, required substantial to maximal assistance with toileting due to severe cognitive impairment and frequent incontinence. Despite a care plan that included frequent checks and assistance with toileting, documentation revealed multiple instances where Resident 31 was left incontinent, and a public complaint confirmed that staff ignored the resident's request for assistance, resulting in an incontinence episode. Staff interviews corroborated that Resident 31 was sometimes left unattended due to other tasks. Resident 240, admitted with diagnoses including stroke and anxiety, required extensive assistance with self-care and was scheduled for bathing twice a week. However, documentation showed significant gaps in bathing care, with multiple instances of missed or refused showers without proper follow-up or documentation. A public complaint alleged that staff denied Resident 240 showers, and staff interviews confirmed that some CNAs did not assist residents they disliked. The DNS stated that refusals should be documented after multiple attempts and nurse verification, but no additional information was found in Resident 240's records.
Failure to Complete CNA Annual Performance Review
Penalty
Summary
The facility failed to complete annual performance reviews for a Certified Nursing Assistant (CNA), identified as Staff 35, who was hired on May 22, 2022. This deficiency was identified during a review of the most recent performance reviews for CNA staff, where no documentation was provided for Staff 35. On October 29, 2024, the Administrator, identified as Staff 1, confirmed the absence of a performance review for Staff 35.
Failure to Post Accurate Staffing Information
Penalty
Summary
The facility failed to post accurate and complete staffing information, as required, which placed residents at risk for incomplete and inaccurate staffing information. Observations of the Direct Care Staff Daily Reports (DCSDR) from October 21, 2024, through October 25, 2024, revealed several deficiencies. On October 21, 2024, at 11:52 AM, no census was documented for the day shift. On October 22, 2024, at 6:51 AM, the DCSDR for that day was not posted, and similarly, on October 23, 2024, at 8:09 AM, the DCSDR was not posted. On October 25, 2024, at 10:31 AM, no census was documented for the day shift. Additionally, a review of the DCSDR from October 1, 2024, through October 20, 2024, showed no census was documented on the evening and night shifts.
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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