Salem Transitional Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Salem, Oregon.
- Location
- 3445 Boone Road Se, Salem, Oregon 97317
- CMS Provider Number
- 385234
- Inspections on file
- 29
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Salem Transitional Care during CMS and state inspections, most recent first.
A resident admitted with sepsis, pneumonia, and acute respiratory failure, who was cognitively intact but dependent for wheelchair mobility, was assisted back to their room after dinner and left alone in a wheelchair while staff sought a second person for a two-person transfer. Staff did not return for over an hour, and the resident reported being alone for more than an hour without a call light or phone within reach, experiencing pain and being unable to transfer or move the wheelchair independently. A CNA assigned to both the resident and dining room duties stated she could not leave the dining room and had asked another CNA to assist, later finding the resident still waiting in the wheelchair, and facility leadership acknowledged the transfer assistance was not provided in a timely manner.
A resident with a right lower leg fracture and intact cognition had a STAT physician order for Lokelma to treat elevated potassium, but the facility failed to administer the medication as ordered. The missed STAT dose was identified in facility documentation, and the on-call provider was notified, after which the resident was sent to the ER. A hospital social worker confirmed the medication was not given and that the transfer was related to the missed dose. An LPN and an RN/RCM both recalled a medication error involving Lokelma, and facility leadership acknowledged the resident should have received the STAT medication.
A resident with kidney disease sustained superficial burns after being given a heat pack by a CNA without nurse approval, a protective barrier, or supervision. The resident applied the heat pack independently and kept it on for an unknown duration, resulting in blisters and skin redness that were discovered the following day.
Annual performance reviews for CNA staff were not completed as required, with some reviews missing for several years and one CNA lacking any documented review. The DNS confirmed that timely annual reviews were expected but had not been conducted for the sampled staff.
The facility did not ensure that CNAs completed the required 12 hours of annual in-service training, as evidenced by documentation showing several CNAs with incomplete or missing training hours. Facility leadership confirmed the expectation for annual training completion.
A resident with kidney failure was admitted with an external urinary catheter, but the care plan lacked documentation of the catheter and there was no physician order on the TAR. An LPN changed the catheter without reviewing a physician's order and documented the change in notes instead of the TAR, contrary to facility policy.
A resident with a history of stroke was given medications all at once by a CNA, despite the resident's clear preference and repeated requests to take medications one at a time with water or applesauce. The resident and a friend attempted to intervene, and a nurse ultimately stopped the improper administration. The resident's preference was later documented for staff.
A resident with brain cancer and stroke was given medications by a CNA who was not authorized to do so, after a CMA left the medications unattended in the room. Despite the resident's repeated refusals and protests, the CNA continued to administer the medications until other staff intervened. Facility policy and staff interviews confirmed that only licensed or certified staff may administer medications and that staff must stop if a resident refuses care.
A resident with significant medical conditions was subjected to unsafe medication administration when a CNA, not authorized to give medications, attempted to administer them after a CMA left the medications unattended in the resident's room. The resident and a friend protested, and the incident was stopped only after intervention by other staff. Staff interviews confirmed the CNA was aware she was not permitted to administer medications.
Two residents experienced deficiencies in pressure ulcer care, including lack of timely assessment, failure to update care plans, and inadequate documentation. One resident developed toe discoloration from compression socks without proper follow-up, while another developed a Stage 2 sacral wound that was not promptly identified or reported. Required protocols for wound monitoring and care plan updates were not followed.
Two residents did not receive timely pharmaceutical services when ordered medications for thrush and hypertension were repeatedly unavailable. Staff were unable to locate the medications on several occasions, and there was confusion regarding medication orders and reordering procedures. The DON expected staff to contact the pharmacy when medications were missing, but gaps in administration still occurred.
A resident was administered ibuprofen as a scheduled medication instead of as needed (PRN) due to a transcription error in the MAR. This led to multiple unnecessary doses, after which the resident experienced significant GI bleeding and was hospitalized. The error was not detected during order entry or review, and the facility's investigation confirmed the medication was given contrary to the physician's original PRN order.
A resident with dementia and a speech deficit was not treated with dignity by an LPN, who taunted the resident to yell louder and incorrectly transferred them by picking them up like a baby. The LPN admitted to becoming annoyed with the resident's behavior and used a not-so-nice tone. These actions were reported by other staff members, leading to the LPN's termination.
An LPN failed to adhere to professional standards by intimidating a resident with dementia and a stroke, who exhibited behaviors like yelling. The LPN admitted to using a harsh tone and physically scooping the resident for transfers, actions that were disrespectful and contrary to the resident's care plan.
A facility failed to report an allegation of verbal abuse involving a resident to the SSA within the required two-hour timeframe. The incident, which involved an agency nurse being rude and causing pain during a dressing change, was reported 18 days late due to leadership changes within the facility.
A facility failed to thoroughly investigate a verbal abuse allegation involving a cognitively intact resident with bilateral leg fractures and chronic pain. The incident was initially treated as a grievance, and the investigation lacked critical elements such as observations, interviews, and record reviews. Staff acknowledged the insufficiency of their investigation process, placing residents at risk for potential ongoing abuse.
Failure to Provide Timely Transfer Assistance and Access to Call System
Penalty
Summary
The deficiency involves the facility’s failure to provide timely transfer assistance to a resident who required staff support for activities of daily living. The resident was admitted with sepsis, lobar pneumonia, and acute respiratory failure with hypoxia, and the admission MDS documented a BIMS score of 14, indicating the resident was cognitively intact but dependent for wheelchair mobility. A nursing care note documented that after dinner the resident was assisted back to their room and left alone in a wheelchair while staff went to obtain a second person for a two-person transfer. Staff did not return to the room for over an hour. A risk management report completed by an LPN confirmed the resident remained alone in the wheelchair in the room for over an hour awaiting transfer assistance. The resident later stated they were left alone for approximately one hour and ten minutes, did not have a call light or phone within reach, experienced pain, and were unable to transfer or move the wheelchair independently. A CNA reported being assigned both to the resident and to dining room duties and stated she could not leave the dining room while residents were still eating, so she requested another CNA to assist the resident back to the room; she later found the resident still sitting alone in the wheelchair awaiting transfer to bed. Multiple facility leaders, including the assistant administrator in training, field lead, chief nursing officer, and assistant chief nursing officer, acknowledged the resident should have received more timely transfer assistance.
Failure to Administer STAT-Ordered Lokelma for Elevated Potassium
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s STAT medication order for a resident with an elevated potassium level. The resident was admitted with a diagnosis of a right lower leg fracture and had a BIMS score of 13, indicating intact cognition. A STAT order for Lokelma, a medication used to treat high blood potassium levels, was placed on 8/1/25. According to the facility’s Risk Management report and a Progress Note dated 8/3/25, the facility did not administer the ordered STAT dose of Lokelma. As a result of the missed medication, the on-call provider was notified and the resident was sent to the emergency room on 8/3/25. During interviews, a hospital social worker stated the facility failed to administer the physician-ordered medication for the resident’s elevated potassium level and confirmed the resident was sent to the hospital related to the missed dose. An LPN reported that a medication error occurred involving the Lokelma dose and stated that an incident report should have been written, though they could not recall if one was completed. An RN/Resident Care Manager also recalled a medication error involving the Lokelma but could not remember details of the findings. Administrative and nursing leadership staff acknowledged that the resident should have received the STAT Lokelma dose as ordered.
Resident Sustains Burns Due to Improper Heat Pack Application
Penalty
Summary
A resident with kidney disease, who was cognitively intact and required partial assistance with upper body dressing, was admitted without any skin impairment. The resident had standing orders for a heat pack, but these orders were not transcribed onto the Treatment Administration Record (TAR). On one occasion, a CNA provided the resident with an insta-hot heat pack without first communicating with a nurse or ensuring a barrier was placed between the heat pack and the resident's skin. The CNA handed the heat pack directly to the resident, who then applied it herself/himself. Staff did not monitor or ensure the timely removal of the heat pack. As a result, the resident kept the heat pack on for an unknown period, leading to the development of superficial blisters and redness on the shoulder and underarm. The next morning, the resident reported itching, and upon assessment, clear and uncapped blisters were observed, with some skin sloughing noted. The incident occurred due to a lack of staff supervision, failure to follow proper procedures for heat pack application, and absence of documentation and communication regarding the intervention.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete annual performance reviews for all five sampled CNA staff members. Personnel records showed that performance reviews for these staff were either outdated by several years or missing entirely. Specifically, one CNA had no performance review on file, while the others had last received reviews between two and seven years prior to the survey. During an interview, the Director of Nursing Services confirmed that annual performance reviews were expected to be completed in a timely manner, but this had not occurred for the sampled staff.
Failure to Ensure Annual CNA In-Service Training Requirements Met
Penalty
Summary
The facility failed to ensure that certified nurse aides (CNAs) received the required 12 hours of in-service training annually. A review of staff training records showed that four out of five randomly selected CNAs had not completed the mandated training hours within the specified timeframes. Specifically, one CNA had only 1.5 hours, another had 2.25 hours, a third had no documented training, and a fourth had 8.62 hours of training documented for the relevant annual periods. During an interview, facility leadership confirmed that CNAs were expected to complete the annual training requirement.
Failure to Provide Adequate Catheter Care and Documentation
Penalty
Summary
The facility failed to provide adequate catheter care for a resident with a history of kidney failure who was admitted with an external urinary catheter. The resident's care plan did not include documentation of the catheter, and there was no physician-ordered treatment for the catheter found on the Treatment Administration Record (TAR). A staff LPN changed the resident's catheter after it became dislodged, but did not review a physician's order prior to the procedure and documented the change in progress notes rather than on the TAR. The facility's policy required verification of a physician's order and care plan review prior to catheter care, but these steps were not followed for this resident.
Failure to Honor Resident's Medication Administration Preferences
Penalty
Summary
A resident with a history of stroke was admitted to the facility and had a specific preference for medication administration, requesting to take medications one pill at a time with water or applesauce. Despite these instructions, a former CNA administered the resident's medications all at once with a spoon, disregarding repeated requests from both the resident and a friend to stop. The friend intervened by notifying a nurse, who then stopped the improper administration. The resident's preference for medication administration was subsequently documented in the care notes and communicated to staff.
Unlicensed Staff Administers Medication Against Resident's Wishes
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA), identified as Staff 30, administered medications to a resident diagnosed with brain cancer and stroke, despite not being licensed or permitted to do so according to state regulations and facility policy. The incident began when a certified medication aide (CMA), Staff 29, entered the resident's room to administer morning medications but found Staff 30 providing personal care. Instead of waiting or returning later, Staff 29 left the medications on the bedside table and exited the room. Staff 30 then attempted to administer the medications to the resident, which was outside her scope of practice. Multiple witnesses, including a friend of the resident and other staff members, observed Staff 30 administering the medications by the spoonful, despite the resident's protests and attempts to refuse, including yelling "no, no, no" and spitting the medications back into the cup. Witnesses reported that Staff 30 did not stop when told to do so by both the resident and the friend. The situation escalated until other staff intervened and removed Staff 30 from the room. Interviews with staff and review of facility policy confirmed that only licensed or certified staff are permitted to administer medications, and that staff are expected to stop any action if a resident refuses care.
Unlicensed Staff Administered Medication Against Resident's Wishes
Penalty
Summary
Facility staff failed to follow professional standards of practice for medication administration for a resident with diagnoses including brain cancer and stroke. A certified medication aide (CMA) entered the resident's room to administer morning medications but found a CNA providing personal care. The CMA left the medications on the bedside table and exited the room, contrary to facility policy and state regulations. The CNA, who was not authorized to administer medications, attempted to give the medications to the resident by the spoonful, despite the resident's verbal refusals and attempts to spit out the medication. A friend of the resident witnessed the event, intervened, and alerted staff at the nurses station. Multiple staff interviews confirmed that the CNA continued to attempt to administer the medications even after being told to stop by both the resident and the friend. The incident was only halted when additional staff, including the CMA and an LPN, entered the room and removed the CNA. Staff acknowledged that only licensed or permitted personnel are allowed to administer medications and that the actions taken were not in accordance with facility policy or professional standards.
Failure to Monitor and Update Care Plans for Pressure Ulcers
Penalty
Summary
The facility failed to ensure proper monitoring and care planning for pressure injuries in two residents. One resident was readmitted with no documented skin impairment but was later found to have redness and discoloration on both great toes, likely related to compression socks. Despite this finding, there were no further assessments or measurements of the affected areas, and the care plan was not updated to reflect the new skin condition. Staff interviews revealed that the areas were not reassessed after the initial finding, and the DNS was not notified of the skin changes, contrary to facility protocol. Another resident was admitted with intact skin but developed a facility-acquired Stage 2 pressure wound to the sacrum and buttocks shortly after admission. The wound was not identified until several days after admission, and the initial wound assessment was inaccurate. The care plan was not revised to address the new wounds, and no incident report was completed as required by facility policy. The DNS acknowledged these lapses, including the failure to notify the physician, initiate an investigation, and document the wound accurately.
Failure to Provide Timely Pharmaceutical Services for Two Residents
Penalty
Summary
The facility failed to provide timely pharmaceutical services for two residents who required medication for their medical conditions. One resident, admitted with cancer, had an order for Nystatin Mouth/Throat Suspension to treat thrush, but the medication was repeatedly unavailable over several days. Progress notes indicated that staff could not locate the medication on multiple occasions, and there was confusion regarding the medication's stop date, resulting in only a small amount being sent by the pharmacy. Staff confirmed the medication was not found in the medication cart or emergency dispensary, and the usual procedure was to notify the nurse and verify if the medication had been ordered. The Director of Nursing expected staff to call the pharmacy if a medication was not available. Another resident, admitted with hypertension and heart disease, had an order for daily isosorbide mononitrate. The medication was not available on several days, as documented in the medication administration records and electronic notes. Staff confirmed the medication could not be located and were unsure if it had been reordered. The pharmacist stated that the medication was ordered and sent out as requested, but gaps in administration occurred due to the medication's unavailability within the facility.
Medication Error: Incorrect Transcription of PRN Ibuprofen Order
Penalty
Summary
The facility failed to ensure that a resident was administered ibuprofen as prescribed, resulting in a significant medication error. The physician ordered ibuprofen 600 mg by mouth every eight hours as needed (PRN) for chills or fever, but the order was incorrectly transcribed into the Medication Administration Record (MAR) as a scheduled medication to be given three times daily. This error led to the resident receiving nine scheduled doses of ibuprofen over several days, rather than only as needed. The error was not identified by the nurse who entered the order or by the second nurse who reviewed it. The resident, who had a diagnosis of obesity and was elderly, subsequently experienced a significant gastrointestinal event, including a large, dark red liquid bowel movement with clots and rectal bleeding. Laboratory results showed low hemoglobin and hematocrit levels, and the resident was transported to the hospital for evaluation and treatment. Hospital records indicated the presence of a duodenal ulcer and diverticula, with an assessment of acute blood loss anemia and suspected diverticular bleed. The facility's investigation confirmed the medication error and noted that the ibuprofen administration may have worsened the resident's condition.
Failure to Treat Resident with Dignity
Penalty
Summary
The facility failed to ensure that residents were treated with dignity, as evidenced by the actions of Staff 3, an LPN, towards a resident with dementia and a speech deficit. The resident, who was admitted with diagnoses including dementia and a stroke, exhibited behaviors such as fidgeting, anger, frustration, and yelling. Despite these known behaviors, Staff 3 was reported to have willfully intimidated the resident by taunting them to yell louder and incorrectly transferring the resident by picking them up like a baby. These actions were observed by other staff members, who reported the incidents to facility management. Staff 3 admitted to becoming annoyed with the resident's yelling and acknowledged using a not-so-nice tone to remind the resident to be quiet. Additionally, Staff 3 stood over the resident in a manner described as dangling a treat if the resident behaved, further demonstrating a lack of respect and dignity towards the resident. The facility's Dignity Policy, which requires staff to treat residents with dignity and speak respectfully, was not adhered to in this instance, leading to the termination of Staff 3's employment.
LPN Fails to Adhere to Professional Standards of Resident Dignity
Penalty
Summary
The facility failed to ensure that a Licensed Practical Nurse (LPN), identified as Staff 3, adhered to professional standards of practice concerning residents' dignity and plan of care. This deficiency was identified during an investigation into the treatment of a resident admitted with dementia and a stroke with speech deficit. The resident's care plan, revised in August 2024, noted behaviors such as fidgeting, anger, frustration, and yelling, with specific triggers and interventions outlined. However, on October 15, 2024, Staff 3 admitted to becoming annoyed with the resident's yelling and frequently reminded the resident to be quiet in a harsh tone. Additionally, Staff 3 stood over the resident while they yelled and physically scooped the resident up for transfers, actions that were deemed intimidating and disrespectful, thus failing to respect the resident's dignity and rights as per the care plan.
Failure to Timely Report Verbal Abuse Incident
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident to the State Survey Agency (SSA) within the required two-hour timeframe. The incident occurred on 1/18/24 when the resident, who was cognitively intact and had bilateral leg fractures and chronic pain, reported that an agency nurse was rude and disrespectful during a dressing change and did not use caution when moving the resident's fractured leg. The resident reported the incident to a Licensed Practical Nurse (LPN) who assisted in completing a grievance form and attempted to contact the agency nurse but did not receive a response. The resident and their family later reported additional concerns about the incident, including experiencing pain and feeling frightened, but the facility did not report the incident to the SSA until 2/13/24, 18 days after the initial report. During an interview on 5/17/24, facility staff acknowledged that the verbal abuse incident was not reported to the SSA in a timely manner. The delay in reporting was attributed to leadership changes within the facility, which led to a review of the grievance log and the eventual determination that the incident should have been reported. The failure to report the incident promptly placed residents at risk for potential ongoing abuse.
Failure to Investigate Verbal Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of verbal abuse involving a resident who was admitted with bilateral leg fractures and chronic pain. The resident, who was cognitively intact, reported that an agency nurse was rude, disrespectful, and failed to use caution during a dressing change. Despite the resident filing grievance forms on two occasions, the facility delayed reporting the incident to the State Survey Agency by 18 days and did not conduct a comprehensive investigation. The initial investigation lacked critical elements such as observations of the resident following the allegation, interviews with potential witnesses or staff, and a thorough review of relevant records. During an interview, facility staff acknowledged that the incident was initially treated as a grievance rather than an abuse allegation. The Director of Nursing Services and other staff members admitted that their investigation process was insufficient and did not meet the required standards for handling abuse allegations. The failure to conduct a thorough investigation placed residents at risk for potential ongoing abuse.
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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