Saint Helens Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Helens, Oregon.
- Location
- 75 Shore Drive, Saint Helens, Oregon 97051
- CMS Provider Number
- 385222
- Inspections on file
- 30
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Saint Helens Post Acute during CMS and state inspections, most recent first.
The facility failed to timely report two separate allegations of abuse and neglect to the State Agency. In one case, a resident with severe cognitive impairment and an anoxic brain injury developed significant swelling and bruising of the right knee, later confirmed as a fracture, which was known to staff but not promptly reported to administration or the State Agency. In another case, a resident with dementia and moderate cognitive impairment, dependent on toileting and personal hygiene, was allegedly left without incontinence care for an entire CNA shift, and this neglect allegation was not reported to the State Agency within the required two-hour timeframe. Leadership, including the DON and Administrator, acknowledged that both incidents were reported late.
A resident with an anoxic brain injury, severe cognitive impairment, and poor impulse control developed swelling and later bruising of the right knee, which an RN assessed as significantly bruised and swollen before ordering an x-ray that confirmed a fracture. The DNS initially assessed the knee swelling without bruising and concluded the injury was likely self-inflicted, and a subsequent facility report attributed the injury to the resident kicking the bed footboard. The resident could not explain how the injury occurred, the RN did not believe it was self-inflicted, and there was no documented evidence that a thorough investigation into this injury of unknown source was completed, as confirmed by the Administrator.
A resident with hypothyroidism and other chronic conditions had a physician order for daily oral thyroid medication, but multiple doses were not administered over several days, as documented on the MAR and in nursing notes indicating the drug was on order, unavailable, and later on pharmacy back-order. Although staff contacted the pharmacy and noted an expected delivery, there was no documentation that the provider was notified of the missed doses or that an alternative source for the medication was pursued. In interviews, an LPN described a process for notifying leadership and the provider when medications are unavailable, and facility leadership stated they would have expected the provider to be informed of the unavailability and missed doses.
A resident undergoing evaluation for TB was not consistently placed on airborne precautions as ordered. The resident participated in group therapy and communal activities without a mask, and staff frequently entered the shared room without PPE or following infection control protocols. The airborne precaution signage was incomplete, and staff were not fully aware of the required practices, resulting in a failure to implement proper infection control measures.
A resident with dementia and agitation pulled on another resident's indwelling catheter while the latter was sleeping, resulting in the catheter tubing being forcibly removed and causing severe pain. Staff and the resident confirmed the incident led to significant distress and ongoing discomfort, with multiple CNAs witnessing the aftermath and providing support.
A resident with Parkinson's disease had discrepancies between the MAR and narcotic logbook regarding Tramadol administration, with records showing conflicting information about the number and timing of doses given. Staff, including several LPNs and the DNS, confirmed the inconsistency but could not recall specific details about the medication administration.
The facility did not ensure RN coverage for at least eight consecutive hours per day on several occasions, as identified in staffing reports. This deficiency was confirmed by the Staffing Coordinator and Executive Director, acknowledging the failure to meet required staffing levels.
The facility did not implement a QAPI program to address quality deficiencies related to abuse, investigations, timely reporting, and immunizations, risking suboptimal resident care. The QAPI policy emphasized a proactive approach, but the Executive Director failed to ensure annual reviews by the QAA committee. Staff confirmed the absence of a relevant QAPI program.
The facility failed to implement effective systems for identifying problems and improving performance, as evidenced by the absence of procedures for problem identification, analysis, and monitoring in their 2024 QAA records. Despite having a QAPI Plan covering various services, there was no evidence of enacted procedures for systematic analysis and performance improvement, acknowledged by the DNS and Regional Director of Clinical Operations.
The facility did not ensure that state survey inspection results were accessible to residents and the public. The notice was placed too high for wheelchair users, and the survey binder was missing from its designated location. Residents were unaware of where to find the results, and the binders were stored out of reach behind the nurses' station.
Expired medications were found in the medication storage room and on multiple medication carts in the facility. Staff members, including CMAs and an LPN, confirmed the presence of expired medications such as Latanoprost eyedrops, MiraLAX, and Lispro insulin, but were unsure about the facility's policy on handling expired medications. The DNS stated that the policy required regular checks and removal of expired medications.
During an influenza outbreak, the facility failed to monitor dishwasher temperatures daily, risking communicable diseases and un-sanitized dishware. The temperature log for the low-temperature dishwasher had multiple blanks for January 2025. Staff confirmed the logs were to be filled out daily, and the dietary manager stated all kitchen staff were in-serviced on the procedure.
The facility's assessment was incomplete, lacking critical evaluations such as third-party agreements, risk assessments, and infection control plans. It also failed to consider resident care needs and cultural factors, placing residents at risk for inadequate care.
The facility failed to ensure that three cognitively intact residents understood the arbitration agreement they signed upon admission. Despite the Business Office Manager's claim that the form was explained and questions were welcomed, the residents either did not remember signing the form or did not understand what arbitration meant. This oversight placed residents at risk of being uninformed about their legal rights.
The facility failed to offer influenza vaccines to two residents, one with traumatic brain injury and another with COPD, despite consents being in place. Documentation was lacking for the administration of the vaccine in 2024, and staff interviews revealed issues with obtaining consents, particularly with agency staff.
The facility failed to provide two residents with information about the risks and benefits of the COVID-19 vaccine, as required by policy. One resident, admitted in 2014 with a traumatic brain injury, had a representative refuse the vaccine in 2023, but there was no documentation of information being provided in 2024. Another resident, admitted in 2024 with COPD, also lacked documentation of receiving vaccine information. Staff interviews revealed issues with obtaining consents, particularly with agency staff.
A facility failed to maintain a comfortable environment in a shower room, leading to an uncomfortable bathing experience for residents. A resident reported cold ambient air, and a surveyor confirmed the issue, noting a sign warning against using the heater due to a fire hazard. The Executive Director acknowledged the problem and confirmed the heater needed replacement.
The facility failed to thoroughly investigate and document abuse allegations involving staff and residents. In multiple instances, investigations lacked statements from alleged perpetrators, and there was no documentation of complaints or disciplinary actions. The facility did not conduct staff training related to abuse or have a tracking system for abuse concerns, and there were no PIPs or audits in place for abuse allegations.
The facility failed to report allegations of verbal and physical abuse within the mandated timeframe for three residents, placing them at risk for further abuse. A resident with cirrhosis and cognitive impairment was allegedly verbally abused by a CNA, but the incident was reported three days late. Another resident with a history of stroke reported potential abuse, but the FRI was submitted a day late. A third resident experienced potential verbal abuse, with the FRI submitted three days late. The DNS confirmed these delays, which did not meet the required reporting timeframe.
The facility failed to thoroughly investigate alleged abuse incidents involving three residents. Investigations lacked statements from accused staff and witnesses, leading to incomplete documentation and premature staff termination. No abuse audits were conducted following these allegations.
The facility failed to follow care plans and physician orders for three residents, leading to delayed treatment and unmet needs. A resident with epilepsy did not have required Dilantin level monitoring, resulting in hospitalization for toxicity. Another resident on anticoagulant therapy had unmonitored bruising, and a third resident involved in an alleged abuse incident had no documented skin or behavior monitoring.
A facility failed to provide timely Notification of Medicare Non-Coverage (NOMNC) letters to a resident, which is necessary to inform them of their right to appeal the termination of services. The resident was not notified of the scheduled end of services, as confirmed by the Executive Director and Social Services Director.
A resident with dental caries and broken teeth did not have their dental needs addressed in their care plan for nearly a year after admission. Despite staff awareness and a request for a dental visit, no action was taken, and a comprehensive care plan was only established much later.
A resident with a traumatic brain injury and contractures was not provided adequate incontinence care, as required by their care plan. Staff and family observations indicated that the resident was not always cleaned properly, with feces left in the groin area. The issue was reported to the administration, but they were unaware of any current concerns, and no grievance had been filed.
A resident with dental caries and broken teeth did not receive timely dental care, despite staff awareness and documentation of the issue. The resident's care plan lacked any reference to dental needs, and a dental appointment was only scheduled over a year after admission.
A resident's Oxycodone, brought from home due to a pharmacy delay, was misappropriated in an LTC facility. Discrepancies between the MAR and narcotic logbook were found, and the medication was not returned upon discharge. Staff interviews revealed a lack of procedures for handling medications brought from home.
A facility failed to provide restorative services to a resident with lupus, depression, and obesity, who wished to exercise to gain strength for discharge. Despite being cognitively intact, the resident received no exercise opportunities or equipment, and staff confirmed the absence of restorative services due to staffing issues. The administrator acknowledged the deficiency and the need to maintain residents' physical strength.
A resident with encephalopathy and dementia was discharged from the facility without receiving a written discharge notice. The resident's representative was also not notified or provided with documentation of the discharge. Staff confirmed that the necessary discharge paperwork was not completed or given to the resident before the discharge.
A resident with dementia and encephalopathy eloped from the facility due to inadequate supervision. The resident, identified as a fall risk, was found a mile away from the facility. Staff interviews and records confirmed that the facility was short-staffed, lacking two CNAs on the day of the incident, which contributed to the inability to monitor residents effectively.
Failure to Timely Report Allegations of Abuse and Neglect to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report allegations of abuse and neglect to the State Agency as required. For one resident with an anoxic brain injury, severe cognitive impairment, and a BIMS score of 0, staff first noted swelling of the right knee on 10/11/25. An RN later observed significant bruising and swelling and ordered an x-ray, which identified a right knee fracture. The facility’s investigation concluded the injury was likely self-initiated from kicking the bed’s footboard, but the RN stated the resident did not know how the injury occurred and she did not believe it was self-inflicted. The DNS stated staff became aware of the knee swelling on 10/11/25, but administration did not report the incident until 10/13/25, and she acknowledged she was aware of the incident but had not reported it to the State Agency because staff failed to report it to management. An LPN confirmed she was initially made aware of the suspected injury on 10/11/25 and did not report it to administration, assuming the facility was already aware. The Administrator confirmed the facility did not report the incident within the required time. The deficiency also includes a separate neglect allegation involving another resident with dementia, a BIMS score of 11 indicating moderate impairment, and dependence on toileting and personal hygiene. A facility-reported incident documented that on 3/15/25 a CNA allegedly failed to complete incontinence care for this resident throughout an eight-hour shift. The DON confirmed the facility reported this neglect allegation to the State Agency on 3/17/25, acknowledging it should have been reported within two hours. The Administrator also confirmed the facility did not report this neglect allegation within the required time frame.
Failure to Thoroughly Investigate Resident’s Knee Fracture of Unknown Source
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to conduct a thorough investigation into an injury of unknown source for one resident. The resident, admitted in 2/2013, had an anoxic brain injury and a care plan dated 1/12/25 documenting impaired cognitive function, poor impulse control, difficulty with self-expression, decision making, and mental status. A 3/31/25 MDS showed a BIMS score of 0/0, indicating severe cognitive impairment. On 10/11/25, staff first noted swelling of the resident’s right knee. The DNS (Staff 2) reported that upon her examination at that time, she noted no bruising and concluded the injury was likely self-inflicted due to the resident’s poor impulse control. An x-ray ordered on 10/13/25 revealed a right knee fracture. A facility investigation report dated 10/23/25 documented swelling and bruising of the right knee and concluded the injuries were likely from the resident kicking the bed footboard. However, an RN (Staff 26) stated that when she was informed of the swelling and examined the resident, she observed significant bruising and swelling and ordered the x-ray that confirmed the fracture. Staff 26 also stated the resident did not know how the injury occurred and that she did not believe it was self-inflicted. There was no documented evidence that the facility completed a thorough investigation into this injury of unknown source, and the Administrator (Staff 1) confirmed that the facility did not thoroughly investigate the resident’s injury.
Failure to Administer Ordered Thyroid Medication and Notify Provider
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order for thyroid medication for one resident. The resident was admitted in December 2024 with diagnoses including polyneuropathy, inflammatory cervical spondylosis, and hypothyroidism. A physician’s order dated 1/4/2025 directed that the resident receive Thyroid Oral 90 mg daily by mouth for hypothyroidism. The January 2025 MAR showed that the thyroid medication was not administered on 1/19, 1/20, 1/22, 1/23, and 1/24, with directions to see nursing notes. Nursing progress notes on 1/19 and 1/20 documented that the thyroid medication was on order, and notes on 1/22 and 1/23 documented that the medication was unavailable. On 1/24, nursing documentation indicated the facility contacted the pharmacy and was informed the thyroid medication was on back-order, with a later note the same day stating the medication was expected to be delivered that night. Review of the clinical record showed no documentation that the provider was notified of the missed doses or that attempts were made to obtain the medication from an alternative source. In interviews, an LPN stated that if a medication was out or on back-order, she would notify the RCM or DNS and they would reach out to the provider for a possible substitute, and the Administrator and DNS stated they would have expected the provider to be notified of the medication being unavailable and of the missed doses. The surveyors determined that the facility’s failure to follow the physician’s order for thyroid medication placed residents at risk for unmet medication needs.
Failure to Implement Airborne Precautions for TB Evaluation
Penalty
Summary
The facility failed to implement airborne precautions for a resident who was being evaluated for tuberculosis (TB). The resident was admitted with a history of cerebral infarction and, following a physician's order, received a TB test and subsequently had a chest x-ray ordered to rule out TB. An order for airborne precautions, including the use of N95 masks and keeping the resident's room door closed, was issued. However, the resident continued to participate in physical therapy and group sessions in communal areas without wearing a mask, and staff did not consistently use personal protective equipment (PPE) when entering the resident's room. The airborne precaution sign on the resident's door was handwritten and did not provide full instructions, and the door to the shared room was often left open with other residents present. Multiple staff members, including CNAs and LPNs, reported entering the resident's room and assisting the resident without PPE, and were unaware of any specialized infection control practices required. The resident confirmed that staff did not consistently wear PPE and that they were not instructed to wear PPE or sanitize hands when outside the room or during therapy. The Director of Nursing Services acknowledged that the airborne precautions were not fully implemented as required, and that staff were expected to follow these precautions until the chest x-ray results were received.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when one resident with dementia and agitation pulled on another resident's indwelling catheter while the latter was sleeping. The incident occurred when a CNA heard the cognitively intact resident yelling and entered the room to find the confused resident holding the catheter urine collection bag, which had been forcibly removed. The resident who experienced the abuse reported severe pain during and after the incident, and staff interviews confirmed the resident was in significant distress for several days following the event. The facility's abuse policy defines physical abuse as the willful infliction of injury resulting in harm, pain, or mental anguish, and requires residents to be protected from such abuse. Multiple staff members recalled the incident, describing the resident's pain and emotional distress, and noted that the resident with dementia was confused at the time. The incident report and staff interviews confirmed that the resident's catheter tubing was broken off during the event, causing ongoing pain and requiring staff support until the resident received pain medication.
Inaccurate Medication Records for Resident Receiving Tramadol
Penalty
Summary
The facility failed to ensure the accuracy of medical records for one resident with a diagnosis of Parkinson's disease. Upon review, discrepancies were found between the resident's Medication Administration Record (MAR) and the facility's narcotic logbook regarding the administration of Tramadol. The MAR indicated the resident received one dose on two separate days, while the narcotic logbook documented two doses on one day and one dose on the following day. Additionally, a family member reported being told the resident received a dose on a different day not reflected in the MAR. Interviews with multiple LPNs and the Director of Nursing Services confirmed the inconsistency between the records and acknowledged that the MAR and narcotic logbook should match, but staff could not recall specifics about the resident or the medication administration events.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was available for at least eight consecutive hours per day, seven days per week, for four out of 68 days reviewed for staffing. This deficiency was identified through a review of the Payroll Based Journal (PBJ) Staffing Data Report for Quarter 4, which revealed that on specific dates in July, August, and September 2024, RN coverage was not available for the required duration. Additionally, the Direct Care Staff Daily Reports from December 13, 2024, through January 13, 2025, indicated a similar lack of RN coverage on December 22, 2024. Interviews with the Staffing Coordinator and the Executive Director confirmed the absence of RN coverage on the identified days, acknowledging the facility's failure to meet the required staffing levels.
Failure to Implement Effective QAPI Program
Penalty
Summary
The facility failed to implement a Quality Assessment and Performance Improvement (QAPI) program that effectively identified and addressed quality deficiencies. Specifically, the facility did not initiate a QAPI review concerning issues related to abuse, investigations, timely reporting, and immunizations. This lack of action placed residents at risk of not receiving optimal care and services. The facility's QAPI policy, last reviewed in May 2023, emphasized a data-driven and proactive approach to quality improvement, yet the Executive Director did not ensure the QAPI plan was reviewed annually by the Quality Assessment and Assurance (QAA) committee. During an interview, the Director of Nursing Services (DNS) and the Regional Director of Clinical Operations confirmed the absence of a QAPI program addressing these concerns.
Lack of Effective QAA Systems in Facility
Penalty
Summary
The facility failed to implement effective systems for identifying problems and taking action to improve and monitor performance, as evidenced by the lack of procedures related to problem identification, analysis, performance improvement, and monitoring in their Quality Assessment and Assurance (QAA) records for 2024. The facility's Quality Assurance and Performance Improvement (QAPI) Plan included oversight of various services and processes, but there was no evidence of enacted procedures for systematic analysis and performance improvement. This deficiency was acknowledged by the Director of Nursing Services (DNS) and the Regional Director of Clinical Operations, placing residents at risk for worsening care.
Inaccessible State Survey Results
Penalty
Summary
The facility failed to ensure that the state survey inspection results were readily accessible to residents and the public. Observations on multiple dates revealed that the notice of survey results was placed approximately five feet high on the wall near the front entrance, making it difficult for individuals in wheelchairs to see. Additionally, the state survey binder, which was supposed to be in a basket below the notice, was missing. During a resident council interview, seven residents indicated they were unaware of where to find the state survey inspection results. The Executive Director confirmed that the survey binders were located on a shelf behind the nurses' station, about six feet high, further limiting accessibility for residents in wheelchairs.
Expired Medications Found in Storage Room and Carts
Penalty
Summary
The facility failed to ensure expired medications were removed from the medication storage room and medication carts, as observed during a survey. In the medication storage room, expired medications including Latanoprost eyedrops, Zioptan eyedrops, and Cephazolin vials were found. Staff 26, a Certified Medication Aide (CMA), confirmed the presence of these expired medications and acknowledged that the facility policy required their removal. However, the expired medications were not separated from other medications as per the facility's policy. Additionally, expired medications were found on multiple medication carts. On the Hall B medication cart, expired MiraLAX and Lispro insulin were identified, with Staff 27, another CMA, uncertain about the facility's policy but aware of the expectation to remove expired medications. On the Hall A room one to five medication cart, expired mucus relief medication was found, with Staff 28, an LPN, also unsure about the policy but aware of the expectation to remove expired medications. Furthermore, the treatment cart for Hall A and C contained expired hemorrhoid cream, Miconazole 7 cream, and triple antibiotic ointment, with Staff 29, an RN, unsure of the policy but aware of the expectation to reorder and remove expired medications. The Director of Nursing Services (DNS) confirmed that the facility's medication storage policy required regular checks and removal of expired medications by all nursing staff.
Failure to Monitor Dishwasher Temperatures During Influenza Outbreak
Penalty
Summary
The facility failed to ensure that dishwasher temperatures were monitored daily during an influenza outbreak, which placed residents at risk for communicable diseases and un-sanitized dishware and utensils. On January 12, 2025, it was observed that the temperature log for the low-temperature dishwasher in the kitchen had multiple blanks for the month and year, with missing entries for wash, rinse, and parts per million (PPM) measurements on several dates. Staff 39, a cook, confirmed that the logs were supposed to be filled out daily but were not. Staff 35, a dietary aide, confirmed that the missing entries were for January 2025 and stated that the logs were to be completed daily. He mentioned that when the dishwasher was not working, the three-sink method was used, but the dishwasher had been operational during his shifts in the last week. The dietary manager, Staff 37, stated that all kitchen staff were in-serviced on December 24, 2024, and were expected to fill in the logs. The executive director, Staff 1, confirmed the in-service training but provided no additional information.
Incomplete Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct and complete a comprehensive facility-wide assessment, which is crucial for determining the necessary resources to care for residents competently during both day-to-day operations and emergencies. The assessment provided by the facility was found lacking in several critical areas. It did not include a listing of contracts, memorandums of understanding, and other agreements with third parties who provide services or equipment to the facility during normal operations and emergencies. Additionally, there was no facility-based and community-based risk assessment identified in the plan, nor was there an assessment or plan to address continuity of care during an emergency. Furthermore, the assessment failed to consider the care required by the resident population using evidence-based, data-driven methods. This includes evaluating the types of diseases, conditions, physical and behavioral health needs, cognitive disabilities, overall acuity, and other pertinent facts present within the population. The assessment also did not evaluate any ethnic, cultural, or religious factors that may affect the care provided by the facility. Additionally, it lacked infection control-specific information related to current standards, evaluation of services related to communicable diseases, and a plan to ensure timely immunizations. Staff acknowledged the deficiencies in the assessment, and no additional information was provided to address these gaps.
Failure to Ensure Residents Understand Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents understood the meaning of an arbitration agreement, which is a legal document where disputes are resolved with a neutral party rather than in court. This deficiency was identified in three residents who were cognitively intact and had signed the facility's Voluntary Arbitration Agreement form upon admission. Despite the Business Office Manager's assertion that the form was explained to residents and that she was available to answer questions, the residents either did not remember signing the form or did not understand what arbitration meant. Resident 44, admitted with fibromyalgia and asthma, remembered signing a lot of paperwork but not the arbitration agreement. Resident 201, with fibromyalgia and COPD, believed their daughter signed all the paperwork and did not know what arbitration was. Resident 300, admitted with diabetes and a skin infection, also did not remember signing the arbitration agreement and did not understand its meaning. These findings indicate that the facility did not adequately ensure that residents were informed of their legal rights regarding arbitration agreements.
Failure to Offer Influenza Vaccines to Residents
Penalty
Summary
The facility failed to ensure that influenza vaccines were offered to two residents, placing them at risk for respiratory infections. Resident 8, who was admitted in 2014 with diagnoses including traumatic brain injury and contractures, had a consent form signed by their representative on 9/25/23 to receive the influenza vaccine annually. However, there was no documentation in Resident 8's clinical record indicating that the influenza vaccine was offered or received in 2024. Interviews with staff revealed that annual consents should be completed at a resident's care conference, and it was the responsibility of the Director of Nursing Services (DNS) to ensure they were completed yearly. Resident 301, admitted in December 2024 with chronic obstructive pulmonary disease, also did not have documentation of receiving or being offered the influenza vaccine in 2024. The last recorded influenza vaccine for Resident 301 was on 10/3/23. Interviews with staff indicated that vaccine consents are expected to be obtained upon admission, but there were difficulties with agency staff not completing them. This lack of documentation and follow-through on vaccine consents contributed to the deficiency identified by the surveyors.
Failure to Provide COVID-19 Vaccine Information to Residents
Penalty
Summary
The facility failed to ensure that residents received information about the risks and benefits of the COVID-19 vaccine, as required by their policy. This deficiency was identified for two residents. Resident 8, who was admitted in 2014 with a traumatic brain injury and contractures, had a representative refuse the COVID-19 vaccination in September 2023. However, there was no documentation in the resident's clinical record indicating that the risks and benefits of the vaccine were offered or received in 2024. Interviews with staff revealed that annual consents should be completed at a resident's care conference, and it was the responsibility of the Director of Nursing Services (DNS) to ensure they were completed yearly. Resident 301, admitted in December 2024 with chronic obstructive pulmonary disease, also lacked documentation of receiving information about the COVID-19 vaccine's risks and benefits in 2024. The resident's last COVID-19 booster was recorded in December 2022, but no current vaccine consents were found. Staff interviews indicated that obtaining vaccine consents on admission was expected, but there were challenges with agency staff not completing them. This lack of documentation and failure to provide necessary information placed residents at risk of being uninformed about the vaccine.
Shower Room Heater Deficiency
Penalty
Summary
The facility failed to ensure a functional and comfortable environment in one of the three shower rooms reviewed, which placed residents at risk for an uncomfortable bathing experience. On January 12, 2025, a resident reported that the ambient air in the shower room near resident room one was cold during bathing, and the heater in the room could not be used. On January 15, 2025, a State surveyor observed the shower room between rooms one and two and noted that their fingertips became cold after standing there for about 10 minutes. A handwritten sign stating 'DO NOT turn heater on! fire hazard!!' was posted in the shower room. On January 17, 2025, the Executive Director acknowledged awareness of the lack of a heat source in the shower room and confirmed that the heater needed to be replaced.
Failure to Investigate and Document Abuse Allegations
Penalty
Summary
The facility failed to implement and document thorough investigations of alleged abuse incidents involving staff and residents. In one instance, an allegation of staff-to-resident physical abuse was reported, but the investigation did not include statements from the alleged perpetrator or a family witness. The staff member involved was terminated due to multiple complaints, but there was no documentation of these complaints or any disciplinary actions in the personnel file. Additionally, there was no evidence of staff training related to abuse following the incident. In another case, an allegation of staff-to-resident physical abuse was reported, but the investigation again lacked a statement from the alleged perpetrator. The staff member was terminated due to multiple complaints, yet there was no documentation of these complaints or any follow-up actions. The facility did not conduct staff training related to abuse after the incident, and there was no tracking system in place to monitor abuse concerns for coordination with the QAPI committee. The facility's failure to conduct root cause analyses or trend tracking for abuse allegations was evident in another reported incident. The investigation did not include a statement from the alleged perpetrator, and the staff member was terminated due to multiple complaints. There were no PIPs in place for abuse, and no abuse audits were completed. The facility lacked a systematic approach to track and address abuse allegations, relying instead on informal methods that were not documented or shared with the QAPI committee.
Delayed Reporting of Abuse Allegations
Penalty
Summary
The facility failed to report allegations of verbal and physical abuse within the mandated timeframe for three residents, placing them at risk for further abuse. Resident 19, who was admitted with diagnoses including cirrhosis of the liver, mild cognitive impairment, and obesity, was allegedly verbally abused by a CNA upon arrival at the facility. The incident was witnessed by another CNA and reported to an LPN, but the Facility Reported Incident (FRI) was not submitted to the state agency until three days later. Similarly, Resident 23, admitted with a history of stroke and mild cognitive impairment, reported potential abuse, but the FRI was submitted a day after the incident, missing the two-hour reporting requirement. Resident 202, also with a history of stroke and mild cognitive impairment, experienced potential verbal abuse, but the FRI was submitted three days after the incident. In all cases, the Director of Nursing Services (DNS) confirmed the delays in reporting to the state agency. These delays in reporting allegations of abuse did not meet the required timeframe, which is crucial for ensuring the safety and well-being of residents in the facility.
Incomplete Investigations into Alleged Abuse Incidents
Penalty
Summary
The facility failed to thoroughly investigate alleged physical and verbal abuse incidents involving three residents. For Resident 19, the investigation into alleged verbal abuse by a CNA did not include statements from the accused staff member or the family witness present during the incident. The family member later confirmed that no verbal abuse occurred, and the CNA was not given an opportunity to provide their account before being terminated. Similarly, for Resident 16, the investigation into alleged physical abuse by the same CNA lacked statements from both the accused and the family witness. The family member present during the incident stated that the CNA was not rough and did not act inappropriately. The CNA was again not given a chance to explain the situation before being dismissed from the facility. In the case of Resident 202, the investigation into alleged abuse by a different CNA and an unknown staff member was incomplete, lacking identification of the second staff member and additional statements. The accused CNA was not allowed to provide a statement before being barred from the facility. The facility's documentation was insufficient, with missing or incomplete records, and no abuse audits were conducted following these allegations.
Failure to Follow Care Plans and Physician Orders
Penalty
Summary
The facility failed to provide care and treatment as care planned and physician ordered for three residents, leading to delayed treatment and unmet needs. Resident 15, who had a history of cerebral palsy, epilepsy, and phenytoin toxicity, was supposed to have Dilantin levels monitored monthly. However, from April 2024 to July 2024, there was no evidence that the required bloodwork was conducted, despite documentation indicating task completion. This oversight resulted in Resident 15 being hospitalized for Dilantin toxicity in August 2024. Resident 100, admitted with a circulatory disorder and on anticoagulant therapy, had multiple bruises noted upon admission. Despite the care plan requiring monitoring for signs of bleeding, there was no evidence of monitoring for the bruising on the Treatment Administration Record (TAR). Staff interviews revealed a lack of awareness and failure to initiate necessary monitoring orders, leaving the bruising unmonitored. Resident 202, admitted with a history of stroke and mild cognitive impairment, was involved in an alleged abuse incident resulting in an abrasion. The facility's documentation did not include any skin assessment, monitoring, or treatment for the abrasion, nor was there any assessment for psychosocial impact following the incident. Staff acknowledged the expectation for behavior monitoring post-incident, but no evidence of such monitoring was found.
Failure to Provide Timely NOMNC Letters
Penalty
Summary
The facility failed to provide timely Notification of Medicare Non-Coverage (NOMNC) letters to a resident, which is a requirement to inform them of their right to appeal the termination of services. Specifically, for one resident, services were scheduled to end on August 9, 2024, but there was no documented evidence that the resident was notified of this termination. This deficiency was confirmed through interviews with the Executive Director and the Social Services Director, who both verified the absence of documentation indicating that the resident was informed of the end of services.
Failure to Address Resident's Dental Needs in Care Plan
Penalty
Summary
The facility failed to ensure a comprehensive care plan addressed the dental needs of a resident, who was admitted with chronic obstructive pulmonary disease and dental caries. Despite the resident's cognitive intactness and documented dental issues, including broken and missing teeth, the care plan did not address these needs. Observations during the recertification survey revealed the resident had broken, blackish, and missing teeth, and the resident reported informing staff about the dental issues without any action being taken. Staff interviews confirmed awareness of the resident's dental needs, with a CNA acknowledging a request for a dental visit made months prior, and a Social Services staff member recalling discussions about the dental needs but unsure of documentation. The Regional Director of Clinical Operations provided a dental care plan dated almost a year after admission, confirming the lack of a timely comprehensive care plan. The Resident Care Coordinator acknowledged that a comprehensive dental care plan should have been in place within a month of admission, but it was not established until much later.
Inadequate Incontinence Care for Resident
Penalty
Summary
The facility failed to provide adequate incontinence care for a resident with a traumatic brain injury and contractures, who was always incontinent of both bowel and bladder and required staff assistance with toileting. The resident's care plan required frequent checks and peri care after each incontinent episode, but staff interviews and family member observations indicated that the resident was not always cleaned appropriately. A family member reported that the resident's groin area was not trimmed, leading to feces being left in the area, and a CNA confirmed finding feces in the resident's groin hair during her shifts. Staff members reported that the issue of inadequate cleaning during incontinence care was a problem throughout the facility, with feces not being cleaned from sensitive areas. A peri care spray that could assist in cleaning was not always available, and concerns had been reported to the administration. Despite these reports, the facility's administration was not aware of any current concerns regarding incontinence care, and no grievance had been filed by the family regarding the resident's care.
Failure to Provide Timely Dental Care
Penalty
Summary
The facility failed to ensure prompt routine and emergency dental services for a resident with chronic obstructive pulmonary disease and dental caries. The resident was admitted with broken teeth and no dentures, which affected their ability to chew food. Despite being cognitively intact and having documented dental issues, there was no evidence of a dental appointment or follow-up in the resident's electronic health record. The resident's care plan did not address their dental needs, and staff were aware of the resident's condition but did not ensure timely dental care. Observations revealed the resident had broken, blackish, and missing teeth, causing embarrassment and discomfort. The resident expressed that they informed staff about their dental issues upon admission, but no action was taken for over a year. Staff members, including CNAs and social services, acknowledged the resident's dental needs but failed to document or follow up effectively. A dental appointment was eventually scheduled more than a year after admission, highlighting a significant delay in addressing the resident's dental care needs.
Misappropriation of Resident's Medication
Penalty
Summary
The facility failed to protect a resident from misappropriation of their medication, specifically Oxycodone, which was brought from home. The resident, who was admitted with arthritis and stroke, had a physician's order for Oxycodone to manage moderate pain. However, discrepancies were found between the medication administration record (MAR) and the narcotic logbook, indicating a mismatch in the number of tablets administered. The resident reported grievances about the untimely administration of their Oxycodone and mentioned that a family member had brought the medication from home due to a delay caused by an ice storm. The medication was reportedly removed from the resident's room by a nurse and was not returned upon the resident's discharge. Despite an investigation being mentioned, no documentation or grievance form was found to address the missing medication. Interviews with staff revealed a lack of clear procedures for handling medications brought from home. The Director of Nursing Services (DNS) and the Administrator acknowledged the issue but could not recall the investigation's outcome. The facility lacked a policy for removing medications from a resident's room, and there was no evidence that the resident's medication was stored or logged appropriately, leading to the misappropriation of the resident's belongings.
Failure to Provide Restorative Services for Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent further decreases in range of motion for a resident admitted with lupus, depression, and obesity. The resident, who was cognitively intact, expressed a desire to exercise to gain strength for discharge but was not provided with any exercise opportunities or equipment. The resident's health records showed no indication of receiving restorative services, and staff confirmed that the facility did not offer such services due to insufficient staffing. The administrator acknowledged the lack of restorative services and the need to maintain residents' physical strength.
Failure to Provide Discharge Notification
Penalty
Summary
The facility failed to provide a written discharge notice to a resident and did not notify the resident's representative of the discharge. The resident, who was admitted with diagnoses including encephalopathy and dementia, was discharged without receiving the required written notification. On the day of the discharge, neither the resident nor the resident's representative received any written documentation regarding the discharge. Staff interviews confirmed that the discharge paperwork was not completed or provided to the resident prior to the discharge.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident diagnosed with encephalopathy and dementia. The resident, admitted in September 2024, was identified as a fall risk due to visual and sensory communication issues, including night blindness, hearing loss, and vertigo. The care plan included monitoring changes in cognition, decision-making abilities, recall, and awareness of surroundings. However, on October 30, 2024, the resident was found approximately one mile away from the facility, indicating a lapse in supervision. Interviews with staff revealed that the facility was short-staffed on the day of the incident, with two CNAs missing from the day shift. This staffing shortage was confirmed by the facility's Direct Care Daily Staff Report for October 2024. Staff members reported that the lack of sufficient CNA staff contributed to the resident's elopement, as they were unable to safely monitor residents. The Director of Nursing Services confirmed these findings, acknowledging that the staffing issue played a role in the resident's unsupervised departure from the facility.
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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