Secora Rehabilitation Of Cascadia
Inspection history, citations, penalties and survey trends for this long-term care facility in Portland, Oregon.
- Location
- 10435 Se Cora Street, Portland, Oregon 97266
- CMS Provider Number
- 385264
- Inspections on file
- 20
- Latest survey
- August 1, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Secora Rehabilitation Of Cascadia during CMS and state inspections, most recent first.
A resident and the resident's attorney made multiple requests for access to the resident's medical records, including billing and care documentation. The facility only partially fulfilled these requests, with significant delays and incomplete responses, despite repeated follow-ups. The resident did not receive the requested records within the required timeframe, and staff acknowledged the failure to provide timely access.
The facility failed to maintain the required dishwasher temperatures, risking un-sanitized dishware and potential communicable diseases. Observations showed water temperatures consistently below the required 120 degrees F, with trays washed at 90 degrees F and plates at 110 degrees F. The Dietary Manager confirmed the deficiency.
The facility failed to ensure two residents were fully informed about the binding arbitration agreement. One resident's legal representative was unaware of the correct rescission period, while another resident with impaired cognition did not recall consenting to the agreement. The facility's arbitration agreement inaccurately stated the rescission timeframe, confirmed by the Administrator-In-Training.
The facility did not ensure that CNA staff received the mandated 12 hours of annual in-service training. Two CNAs were found to have completed only 7.5 and 1.5 hours of training, respectively. This was confirmed by the Administrator-In-Training and the Clinical Resource, highlighting a failure to adhere to the facility's policy on maintaining staff competence and knowledge.
A resident with vascular dementia and a history of stroke did not receive their prescribed anticoagulant, Rivaroxaban, for three consecutive days. This oversight led to the resident developing stroke-like symptoms and being sent to the hospital. The LPN responsible did not follow protocol by failing to notify staff or the provider about the missed doses.
A resident with major depressive disorder was found with medications on their nightstand without a completed self-administration assessment, contrary to facility policy. Staff confirmed that medications should not be left at the bedside without an assessment, highlighting a failure to ensure safe medication practices.
A facility failed to assist a resident in formulating an advance directive, despite the resident's request for help. The resident, admitted with pneumonia and anxiety, expressed a desire for assistance, but no advance directive was on file. The Social Services Director discussed the matter with the resident, but no follow-up occurred, as confirmed by the facility administrator.
A facility failed to provide adequate showers for a resident with moderate cognitive impairment and incontinence, compromising personal hygiene and dignity. Despite being scheduled for showers twice a week, the resident received them inconsistently, with significant gaps between showers. Staff confirmed that missed showers were not rescheduled due to time constraints, and the DNS acknowledged the failure to meet the facility's policy of providing at least two showers per week.
A facility failed to implement an activity care plan for a non-verbal resident with cerebral palsy, leading to isolation and lack of engagement. The resident was not invited to group activities and was often found lying in bed without access to preferred activities like music or audio books. Staff interviews revealed a lack of coordination and awareness regarding the resident's participation in activities.
The facility failed to comprehensively assess and follow care plans for pressure injuries in two residents. One resident developed a new heel pressure injury that was not properly documented or off-loaded, while another resident's air mattress was incorrectly set, causing discomfort and improper positioning. Staff interviews confirmed non-compliance with care plans, placing residents at risk for worsening conditions.
The facility did not conduct an annual performance review for a CNA hired in 2023, as confirmed by HR staff. This oversight was identified during a personnel record review and poses a risk to resident care due to potential staff incompetence.
A facility failed to provide necessary behavioral health care and develop a comprehensive care plan for a resident with schizoaffective disorder and Bipolar II. Despite the resident's history of behaviors and symptoms of depression, anxiety, and intrusive thoughts of suicide, the facility did not monitor these symptoms or create a care plan. The resident exhibited episodes of yelling and screaming and reported sensations of bugs crawling on them. Staff confirmed the absence of behavior monitoring and care plan interventions.
The facility did not maintain a clean and homelike environment, as air intake floor vents in resident hallways were found with dust, fuzz, and debris. A resident noted that staff swept dust into the vents, and the Housekeeping Manager admitted the vents were cleaned quarterly, with the last cleaning several months ago. The Administrator in Training acknowledged the issue and expected weekly cleaning.
The facility failed to ensure accurate daily postings of nurse staffing data, with 13 out of 38 days showing inaccuracies or incomplete information. The policy required daily postings at the start of each shift, but from mid-February to late March, several days had errors. The Staffing Coordinator confirmed these discrepancies.
A resident with a history of stroke and falls was improperly restrained by a staff member who tied the resident's gait belt to their wheelchair to prevent falls while attending to other residents. The incident was confirmed by another staff member, who found no negative skin findings. The staff member responsible admitted to the action, citing the resident's high fall risk.
A resident with spinal fractures and chronic pain syndrome did not receive prescribed morphine for pain management due to unavailability on the day of admission. Despite reporting severe pain, nursing staff did not utilize the Cubix system to obtain the medication. The resident received the first dose the following morning, expressing upset over the delay.
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to provide timely access to medical records for a resident who was cognitively intact and had diagnoses including morbid obesity and chronic pain. The resident's attorney requested medical records covering a specific period, but only partial records were provided initially, with progress notes sent and billing documentation omitted. Despite eight follow-up requests from the attorney's office over several months, the complete set of records was not released until approximately four months after the initial request. The Business Office Manager acknowledged receiving multiple communications from the attorney's office but did not follow up due to being too busy. The Administrator confirmed that only a portion of the records was provided at first, and the remaining documents were sent much later. Additionally, the resident personally requested copies of their medical records, including specific documents such as history and physical, progress notes, medication list, care plan, financial data, foot wound care documentation, and transportation notes. There was no documentation indicating that the resident received these records within the required timeframe, and the resident confirmed not having received them about a week after the request. The Administrator acknowledged that the records were not delivered or made available to the resident as required by facility policy.
Dishwasher Temperature Deficiency
Penalty
Summary
The facility failed to ensure that the dishwasher temperatures met the minimum requirements, which placed residents at risk for communicable diseases and un-sanitized dishware and utensils. The facility's Dishwashing in the Dish Machine Policy, dated 1/1/2018, requires testing the dish machine for proper water temperatures and sanitizer levels before washing dishware, and not using the machine if these are not acceptable. On 3/27/25, observations were made of the dishwashing process, where the water temperature was consistently below the required 120 degrees F. Specifically, trays were washed at 90 degrees F, plates at 110 degrees F, forks at 115 degrees F, and plates and cups at 118 degrees F. An external thermometer confirmed the water temperature was 118 degrees F, which was below the required minimum for adequate sanitization. Staff 26, the Dietary Manager, acknowledged that the dishwasher water temperature did not meet the minimum requirements.
Failure to Inform Residents of Arbitration Agreement Rights
Penalty
Summary
The facility failed to ensure that residents were fully informed and understood the binding arbitration agreement, affecting two residents. Resident 16, who was admitted with congestive heart failure, had their legal representative sign the arbitration agreement without being informed of the right to rescind it within the correct timeframe. The legal representative was unaware of the right to rescind the agreement within 30 days, as the facility's agreement inaccurately stated a 10-day rescission period. This discrepancy was confirmed by the Administrator-In-Training. Resident 304, admitted with metabolic encephalopathy and severely impaired cognition, was also affected. The resident's records showed a verbal consent to the arbitration agreement, but the resident did not recall signing or understanding the agreement. The facility's arbitration agreement again inaccurately stated the rescission timeframe, which was confirmed by the Administrator-In-Training. These actions placed residents at risk of being uninformed of their legal rights.
Deficiency in CNA In-Service Training Hours
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistant (CNA) staff received the required 12 hours of in-service training annually, as evidenced by the review of training records for two randomly selected staff members. Staff 9 completed only 7.5 hours, and Staff 18 completed only 1.5 hours of the required training. This deficiency was confirmed through interviews with Staff 2, the Administrator-In-Training, and Staff 3, the Clinical Resource, who acknowledged the shortfall in training hours for these staff members. The facility's policy, last revised on October 15, 2022, mandates that employee education and in-service training are provided to maintain staff competence and knowledge, which was not adhered to in this instance.
Failure to Administer Anticoagulant Leads to Hospitalization
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, which placed the resident at risk for adverse side effects. The resident, who was admitted with vascular dementia and a history of stroke, was prescribed Rivaroxaban, an anticoagulant, to be administered daily. However, the medication was not administered on three consecutive days. This oversight was identified through a facility investigation, which revealed that the medication was available but not given by the responsible LPN. As a result of the missed doses, the resident developed stroke-like symptoms and was sent to the hospital emergency department. The investigation further revealed that the LPN did not notify other staff, contact the provider, or call the pharmacy regarding the missed doses. The LPN admitted to being overwhelmed and failing to follow the appropriate protocol, which included notifying the prescriber and completing a medication error report.
Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was assessed for the safe self-administration of medications, which is a requirement according to the facility's policy. The policy states that a resident may self-administer medications if the interdisciplinary team determines it is safe, based on the resident's capacity to follow directions, comprehend instructions, and securely store medications. However, for Resident 28, who was admitted with a diagnosis of major depressive disorder and had no cognitive impairment according to the Annual MDS, no such assessment was completed. Despite this, medications including mycostatin and trimincolone acetonide were observed on the resident's nightstand, accessible to the resident and others entering the room. Staff interviews revealed that medications should not be left at a resident's bedside without a completed self-administration assessment. Staff 11 (CMA) and Staff 10 (CNA) confirmed that an assessment was necessary and that the nurse should be notified if medications were left at the bedside. Staff 4 (DNS) also confirmed that the resident had not been assessed for safe self-medication and that the medications should not have been left in the room. This oversight placed the resident at risk for unsafe medication administration and potential adverse side effects.
Failure to Assist Resident with Advance Directive
Penalty
Summary
The facility failed to assist a resident in formulating an advance directive, as required by their policy. The policy, dated 10/1/17, mandates that if a resident has not executed an advance directive, the facility should advise the resident and family of their right to establish one and offer assistance if desired. Resident 21, admitted in September 2024 with diagnoses including pneumonia and anxiety, expressed a desire for assistance with an advance directive on a form dated 9/16/24. However, a review of the resident's clinical record showed no advance directive on file. Interviews revealed that although the Social Services Director discussed advance directives with the resident upon arrival, no follow-up assistance was provided. The facility administrator confirmed the lack of follow-up in assisting the resident with formulating an advance directive.
Failure to Provide Adequate Showers for Dependent Resident
Penalty
Summary
The facility failed to ensure that a dependent resident received adequate showers, which compromised personal hygiene and dignity. Resident 16, who was admitted with diagnoses including diabetes and morbid obesity, required partial to moderate assistance with bathing due to moderate cognitive impairment. The resident was incontinent of urine and frequently incontinent of bowel, necessitating regular showers. However, the bathing task logs for February and March 2025 indicated that the resident received showers on only five occasions, with significant gaps between them, including an eight-day period without a shower after admission. Interviews with the resident and staff revealed that the resident was scheduled for showers twice a week but did not receive them consistently. The resident expressed a need for more frequent showers due to incontinence, but missed showers were not rescheduled. Staff members confirmed that showers were often missed due to scheduling constraints, and make-up showers were only possible if time allowed. The Director of Nursing Services confirmed that the resident did not receive the expected minimum of two showers per week, as per facility policy.
Failure to Implement Activity Care Plan for Resident
Penalty
Summary
The facility failed to implement an activity care plan and include a resident in group and individual activities, which placed the resident at risk for isolation and lack of social interaction. The resident, who was admitted with diagnoses including metabolic encephalopathy and cerebral palsy, was non-verbal and dependent on staff for care and mobility. Despite having a care plan that indicated the resident should be invited and encouraged to participate in activities, observations showed that the resident was not invited to group activities such as Bingo and was often found lying in bed without any engagement in preferred activities like music or audio books. Staff interviews revealed a lack of awareness and action regarding the resident's participation in activities. The Activities Director admitted to not inviting the resident to group activities and struggled with engaging non-verbal residents. Additionally, the facility had not procured necessary materials like music or audio books, and there was a lack of coordination between the activities staff and CNAs to assist the resident. The Director of Nursing Services expected staff to follow the care plan, which included assisting with turning on televisions and music, but this was not consistently done, contributing to the deficiency.
Failure to Adhere to Pressure Ulcer Care Plans
Penalty
Summary
The facility failed to ensure comprehensive assessment and adherence to care plans for pressure injuries in two residents. Resident 16, admitted with diagnoses including diabetes and acute kidney failure, developed a new pressure injury on the left heel after admission. The Skin and Wound Evaluation for this injury lacked critical details such as the stage of the injury, wound characteristics, and pain assessment. Despite care plan instructions to off-load pressure from the heel using a boot or pillows, observations revealed the resident's heel was not off-loaded, and staff failed to document any refusals by the resident to comply with these interventions. Resident 15, with a history of spinal stenosis and spondylosis, was at moderate risk for pressure sores and required assistance with bed mobility. The care plan specified the use of a specialty air mattress and off-loading of heels with pillows or boots. However, the air mattress was incorrectly set at 50 pounds instead of the prescribed 120 pounds, leading to discomfort and a sunken position for the resident. Observations showed the resident's heels were not off-loaded, and staff failed to adjust the mattress settings or report the resident's discomfort to nursing staff. Both residents were observed in positions that did not comply with their care plans, and staff interviews confirmed a lack of adherence to prescribed interventions. The facility's failure to follow care plans and ensure proper assessment and documentation of pressure injuries placed residents at risk for worsening conditions.
Failure to Conduct Annual Performance Review for CNA
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received annual performance reviews, specifically for one CNA out of four randomly selected staff members. This deficiency was identified during a review of personnel records conducted with the Human Resources staff. It was found that a CNA, hired on November 6, 2023, did not have a completed annual performance evaluation. This oversight was confirmed by the Human Resources staff, placing residents at risk due to the potential lack of care by competent staff.
Failure to Provide Comprehensive Behavioral Health Care Plan
Penalty
Summary
The facility failed to provide necessary behavioral health care and services and develop a comprehensive, person-centered behavioral health care plan for a resident with schizoaffective disorder and Bipolar II. The resident, admitted in February 2025, had a history of behaviors and was prescribed anti-psychotic medications. Despite being identified as having mild depression, anxiety, and intrusive thoughts of suicide, the facility did not monitor these symptoms or develop a care plan to address the resident's anxiety, feelings of helplessness, withdrawal, lack of coping skills, or thoughts of suicide. The resident exhibited multiple episodes of yelling and screaming, reported sensations of bugs crawling on them, and expressed a need for medication to alleviate these sensations. Staff interviews revealed that the resident was often labile, easily frustrated, and had outbursts, yet there was no behavior monitoring or care plan interventions in place. The Social Service Director and CNAs confirmed the absence of a comprehensive behavioral care plan and monitoring for the resident's behaviors. The Director of Nursing Services acknowledged that residents with mental health diagnoses should be monitored and care planned for behaviors, confirming that the resident's triggers were not identified, and strategies to help them feel better were not devised.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment, as evidenced by the accumulation of dust, fuzz, and paper debris on and below the grates covering the air intake floor vents in the north and south residents' hallways and the entrance hallway. These observations were made over several days. A resident reported that staff swept dust from the floors into the vents, contributing to their unclean state. The Maintenance Manager indicated that cleaning the floor vents was a housekeeping responsibility, while the Housekeeping Manager admitted that the vents were cleaned quarterly, with the last cleaning occurring several months prior. The Administrator in Training acknowledged the dirty vents and stated an expectation for weekly cleaning by housekeeping.
Inaccurate Nurse Staffing Reports
Penalty
Summary
The facility failed to ensure the accuracy of the Direct Care Staff Daily Report (DCSDR) postings for 13 out of 38 days reviewed. This deficiency was identified through interviews and record reviews, which revealed that the nurse staffing data was either inaccurate or incomplete on specific days. The facility's policy required daily postings of nurse staffing data at the beginning of each shift, including the facility name, current date, total number of actual hours worked by licensed and unlicensed staff, and the resident census. However, from February 15, 2025, to March 24, 2025, the DCSDRs were found to have inaccuracies or missing information on several days. On March 27, 2025, the Staffing Coordinator confirmed the inaccuracies and incomplete information on the identified days.
Improper Use of Physical Restraints on a Resident
Penalty
Summary
The facility failed to ensure that residents were free from physical restraints, as evidenced by the case of a resident who was improperly restrained. The resident, admitted in May 2023 with a history of stroke and repeated falls, was identified as a high fall risk. The care plan for the resident included encouraging transfers to prevent further falls. However, on June 7, 2023, it was reported that the resident had been placed in a device that limited their ability to stand. A staff member, identified as Staff 11, tied the resident's gait belt to their wheelchair to prevent falls while attending to other residents. The incident was confirmed by Staff 3, who observed the restraint and conducted a skin check with no negative findings. Staff 11 admitted to tying the gait belt to the wheelchair, citing the resident's high fall risk and the need to manage care for other residents. The facility's investigation included a handwritten statement from Staff 11, acknowledging the action taken to keep the resident from falling. The facility's administrator and director of nursing services were informed of the findings but provided no additional information.
Removal Plan
- Educated the staff responsible and placed on corrective discipline;
- Provided in-service training to all nursing staff for abuse and neglect which included the use of restraints;
- Provided signature sheet verifying nursing staff had completed the training.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who was admitted with spinal fractures and chronic pain syndrome. Upon admission, the resident was prescribed morphine tablets to be administered every 12 hours for pain management. However, the resident's medication administration record (MAR) indicated that the morphine was not administered during the evening shift on the day of admission due to the medication being unavailable. The initial pain assessment conducted by a registered nurse revealed that the resident reported a severe pain level of 10. Despite the facility's procedures requiring immediate response to pain complaints and the availability of a medication dispensing system (Cubix) for emergent care needs, there were no documented efforts by the nursing staff to obtain the pain medication from the Cubix. The morphine was eventually delivered to the facility in the early hours of the following day, and the resident received the first dose later that morning. The resident expressed upset over the delay in receiving the medication. Interviews with staff confirmed the lack of timely administration and absence of progress notes explaining the delay.
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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