South Hills Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Eugene, Oregon.
- Location
- 1166 E. 28th Avenue, Eugene, Oregon 97403
- CMS Provider Number
- 385167
- Inspections on file
- 25
- Latest survey
- February 9, 2026
- Citations (last 12 mo.)
- 19 (1 serious)
Citation history
Health deficiencies cited at South Hills Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to follow provider orders and accurately administer medications for three residents. A resident with fractures and kidney disease had a critical low RBC lab; the provider ordered ED transfer after a virtual assessment, but the LPN did not enter or act on the order, did not document it at the time, and the oncoming LPN, despite hearing the ED instruction and later being told of low BP and other concerning symptoms, did not verify or complete the transfer or assess the resident. Separately, a resident with sepsis was ordered Cefazolin q8h, but the order was transcribed as ceftriaxone, leading to 11 doses of the wrong antibiotic, and another resident with PTSD had quetiapine orders changed to 300 mg HS with the AM dose discontinued, yet the AM dose continued to be given, resulting in administration of more quetiapine than ordered.
A resident with diabetes and kidney complications did not receive prescribed insulin glargine on multiple occasions when absent from the facility for dialysis. An LPN was unaware if the medication was administered or sent with the resident, and there was no documented clinical plan for insulin administration during these absences.
A resident with chronic respiratory failure did not receive continuous oxygen therapy as ordered by the physician, resulting in low oxygen saturation until staff discovered the oxygen concentrator was off and restored therapy.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility did not provide adequate CNA staffing on multiple shifts over a one-month period, as confirmed by the Regional Staffing Coordinator, placing residents at risk for unmet needs.
Two kitchen staff failed to follow proper hand washing procedures during food preparation and service, including handling items after contact with dirty surfaces and using the same paper towel to turn off the faucet and dry hands. These actions were confirmed by the dietary manager and placed residents at risk for foodborne illness.
A resident with COPD and muscle weakness was found with two inhalers at the bedside without documentation of assessment or authorization for self-administration. Staff were aware of the inhalers but could not confirm if the resident had been properly assessed, and the inhalers remained in the room without an order or evaluation.
A resident with acute kidney disease and intact cognition developed draining blisters and reported severe discomfort, leading to transfer to the emergency department. Nursing staff documented the symptoms but did not notify the physician of the change in condition prior to the transfer, a lapse confirmed by facility leadership.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Two residents were subjected to repeated verbal abuse involving racial and discriminatory remarks from other residents. Staff failed to intervene appropriately, often advising the affected residents to ignore the comments or avoid the perpetrator, and did not document or report the incidents as required by policy. Facility leadership confirmed awareness of the abuse but did not provide evidence of timely investigation or reporting.
Two residents who were transferred to the hospital did not receive required written notification of the Bed Hold Policy or transfer notice, despite being cognitively intact. Staff and leadership confirmed that the necessary documentation and notifications were not provided at the time of transfer, and the events were not properly recorded in the clinical records.
A resident with a history of stroke, fluency disorder, and depression was admitted and had a physician order for a CBC lab documented in the psychiatric admission note. The medical record showed the CBC was not obtained, and the DNS confirmed unawareness of the order and that the lab was not completed.
A resident with a history of stroke was found on the floor after an unwitnessed fall, and only one neurological assessment was documented despite facility protocol requiring multiple checks. Staff interviews confirmed that expected neurological assessments were not completed or documented.
A facility's exterior refuse container was observed with its lid open, leaving a significant gap, because staff were unable to close it due to a broken cranking mechanism. The Dietary Manager confirmed that staff did not always close the dumpster for this reason.
The facility failed to provide adequate staffing, resulting in unmet needs for residents, including delayed responses to call lights, missed showers, and increased falls. A resident with paraplegia reported long wait times for assistance, while another resident experienced an incontinent episode due to delayed staff response. Staff consistently reported being overburdened, leading to incomplete care tasks and burnout.
The facility failed to maintain accurate and complete staffing information, with discrepancies noted in the Direct Care Staff Daily Reports and time sheets over July and August 2024. Missing census documentation and inconsistencies in reported CNA hours were observed. Further issues were identified in October 2024, with unposted and incomplete DCSDRs. Facility leadership acknowledged the need for additional education for new nursing staff.
A resident with a chronic ulcer and sacrum fracture reported verbal abuse by a CNA, who allegedly raised his voice and called the resident a liar multiple times. The resident, who was cognitively intact, felt verbally abused and reported the incident. The facility's investigation found the allegations unsubstantiated, but noted the CNA should have left the room and reported the situation.
The facility failed to report investigations timely to the State Survey Agency for three residents reviewed for medications, abuse, and neglect. A resident with anxiety and a leg fracture had an incident reported on time, but the investigation report was delayed due to a misunderstanding by the DNS. Another resident with pain and surgical aftercare had an incident reported late, and the investigation report was delayed due to witness contact issues. A third resident with a leg fracture had an incident reported on time, but the investigation report was sent late.
The facility failed to conduct timely and thorough investigations for three residents, leading to potential risks. A resident with arthritis experienced a fall, but the investigation was delayed. Another resident filed a grievance about rough care, but the investigation lacked witness statements and did not address pain medication. A third resident was found unresponsive after medication, but the investigation did not reconcile medications or review narcotic administration. These deficiencies were confirmed by facility staff.
A CNA in an LTC facility engaged in unprofessional conduct with a resident admitted for a leg fracture. The CNA spent excessive time with the resident, massaged her/his hip inappropriately, and provided personal contact information for future caregiving services. This behavior was reported by the resident and a family member, and confirmed by facility staff, as it violated facility policy and constituted a conflict of interest.
Two residents with cognitive impairments did not receive necessary assistance with ADLs due to staffing issues. One resident went without bathing for extended periods, while another experienced incontinent episodes due to delayed assistance. Documentation inconsistencies and staffing shortages were noted.
A facility failed to maintain accurate records for controlled medications, specifically oxycodone, for a resident with a leg fracture. The resident was administered incorrect dosages and frequencies, and discrepancies were found between the Narcotic Logbook and the Medication Administration Record. Staff acknowledged using the same logbook page despite changes in physician orders, leading to incomplete records and potential medication errors.
The facility failed to address resident dining concerns timely, as evidenced by unresolved issues with outdated menus and the lack of weekly menu availability. Despite initial responses, these concerns were not resolved, and staff acknowledged the oversight.
The facility failed to deliver mail on Saturdays for about a month due to the absence of an activity assistant, as confirmed by a resident and the Activity Director during a Resident Council meeting.
The facility failed to ensure past survey results were readily available for residents and visitors. Residents were unaware of the location of the survey results, which were found obscured by unrelated forms in a wall-mounted bin labeled 'Requests, concerns, and suggestions.' The Administrator confirmed this as the usual location for the survey results.
The facility failed to ensure waste was properly contained in the garbage storage area, which was observed to be dirty and disorganized with an open garbage container lid and surrounding debris. Staff acknowledged the state of the area and cited a lack of time to clean it, while another staff member was unaware of any requirement to monitor the area.
The facility failed to address resident choice for dining, affecting five residents. Observations and interviews revealed that daily menus were posted but not easily accessible, and residents expressed dissatisfaction with the lack of meal choices. Staff confirmed the absence of printed menus and acknowledged residents' concerns.
The facility failed to provide adequate supervision and care to prevent accidents for four residents. One resident with dysphagia was left unsupervised during meals, another with severe cognitive impairment eloped twice, a third resident at risk for falls experienced two unwitnessed falls, and a fourth resident with a history of noncompliance with the smoking policy was improperly assessed as an unsupervised smoker.
The facility failed to provide adequate staffing, resulting in prolonged call light wait times and residents experiencing incontinence due to delays in assistance. Multiple residents and staff reported significant delays, with some residents left in soiled conditions or on commodes for extended periods. The facility acknowledged the staffing issues and stated they were actively hiring.
The facility failed to staff an RN for 8 consecutive hours per day, 7 days per week, for 15 out of 123 days reviewed, placing residents at risk for unmet assessment needs. The issue was acknowledged by the facility's administrative and regional staff, who stated they were actively hiring to address the deficiency.
The facility failed to complete annual performance reviews for five CNAs hired between December 2013 and December 2021, as confirmed by the Administrator. This placed residents at risk for receiving care from potentially incompetent staff.
The facility failed to submit mandatory staffing information based on payroll data and other verifiable and auditable data as required by CMS. During an interview, the Administrator, DNS, and other regional directors stated that the corporate office was responsible for submitting the data and they were unaware that it had not been submitted.
The facility failed to follow infection control standards for a resident with a catheter and for handling dirty linens. A resident's catheter bag was improperly attached and in contact with the floor, and a CNA was observed carrying dirty linens without using disposable bags, despite their availability.
The facility failed to assess two residents for self-administration of medications. One resident with kidney disease was not assessed for self-administration of a phosphorous binder, and staff did not administer the medication with meals as required. Another resident with diabetes was found to have medicated cream at their bedside without an assessment for self-administration.
The facility failed to address a resident's missing items timely. Despite reports from the resident's family member about a missing shirt and blanket, no resolution was provided, and no grievance forms were filled out. The staff did not follow the protocol of documenting missing items and responding within seven days.
The facility failed to monitor and assess the continued use of a physical restraint for a resident with muscle wasting and atrophy, who was identified as an elopement risk due to dementia and wandering behavior. Despite documentation inconsistencies and a request to discontinue the Wander Guard, it remained in place, triggering an alarm when the resident was taken out for an appointment. This placed the resident at risk for potential abuse or neglect.
The facility failed to conduct a Significant Change MDS assessment within the required timeframe for a resident admitted to hospice care. The resident, diagnosed with heart disease, was approved for hospice services, but the significant change MDS was not completed within 14 days. The MDS Coordinator acknowledged this oversight.
The facility failed to revise care plans for three residents, including one with changed dialysis times, another admitted to hospice, and a third experiencing pain from hemorrhoids. Staff acknowledged the care plans were not updated to reflect the residents' current needs.
A facility failed to provide elbow braces for a resident with contractures, despite the care plan indicating the need for braces during the day. The braces were inconsistently offered, and staff were unaware of the requirement, leading to compromised mobility and pain for the resident.
The facility failed to provide appropriate catheter care for a resident with a suprapubic catheter, leading to an increased risk of infections. Despite a care plan and a urology clinic note indicating the need for a follow-up appointment and catheter change, the facility did not schedule the necessary follow-up. Additionally, the facility lacked the appropriate supplies to perform the catheter change, further delaying the necessary care.
The facility failed to maintain healthy nutritional parameters for a resident with dysphagia, leading to unsupervised meals, inconsistent care plans, and discontinued nutritional supplements without proper documentation. Staff interviews revealed reliance on verbal reports and unclear physician orders, placing the resident at risk for further weight loss.
A resident with hemorrhoid pain did not receive timely pain management interventions, including prescribed witch hazel pads and a specialized cushion, due to lapses in communication and failure to update the care plan. This resulted in ongoing pain and decreased activity levels.
The facility failed to address pharmacy recommendations for a resident with arthritis and anxiety. A pharmacy review recommended labs to evaluate medications, but there was no evidence the labs were obtained. This was confirmed by the Staff Development Coordinator, indicating the labs were not obtained timely.
The facility failed to obtain routine labs to monitor the effectiveness of medications for a resident. A pharmacy review identified the need for labs to evaluate medications for high cholesterol, diabetes, vitamin D, B12 deficiencies, sodium, and potassium levels. Although the labs were ordered by the physician, they were not obtained until a later date, as confirmed by the Staff Development Coordinator.
The facility failed to adequately monitor psychotropic medications for a resident with bipolar disorder and other conditions. Staff did not consistently document monitoring for adverse reactions, missing numerous opportunities in February and March 2024, which placed the resident at risk for ineffective medication management.
A resident with a history of stroke and abnormal weight loss had a colonoscopy canceled due to refusal to consume preparation medication. The physician was notified, but this was not documented, and the test was not rescheduled, leading to a delay in treatment.
A resident with malnutrition and quadriplegia had her/his teeth extracted and required dentures. Despite a care plan revision and repeated requests, the resident did not receive dentures. The social worker tried to arrange an appointment but was waiting for the DNS to discuss the procedure's risks and benefits. The DNS admitted that follow-up was lacking.
The facility failed to honor snack requests and provide adequate snack inventory for a resident with specific dietary needs and preferences. The snack refrigerator was often inadequately stocked, and residents voiced concerns about insufficient availability of essential snacks like milk, string cheese, and sandwiches. Staff acknowledged the lack of proper monitoring and stocking of high-demand snacks.
The facility failed to notify residents' representatives regarding changes in condition for three residents. One resident tested positive for COVID-19, another had episodes of wandering, and a third had high blood sugar levels, but their representatives were not informed in a timely manner.
The facility failed to ensure rooms were homelike and in good repair for two residents. One resident's bed footboard was damaged and mended with electrical tape, while another resident's room had large gouges and black streaks on the wall. The Maintenance Director was aware of the broken footboard but had not ordered a replacement and was unaware of the wall damage.
Failure to Follow Provider Orders for ED Transfer and Accurate Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and properly act on critical lab values and medication orders for three residents. For one resident with multiple spinal fractures and kidney disease, a critical low red blood cell count was reported to the facility, and the on‑call physician conducted a virtual assessment and ordered the resident sent to the ED via non‑emergent transport for possible blood transfusion. The LPN who received the critical lab and the order did not enter the ED transfer order into the chart, did not act on the transport order, and did not document the provider’s verbal order at the time. She instead wrote a note the following day. Another LPN coming on to the next shift overheard the provider instructing that the resident be sent to the ED and that family be called, but she was not informed of the critical lab or the need to complete the transfer and assumed, without confirming, that the resident had refused transfer. During the evening, the second LPN administered nausea medication twice and was informed by a certified occupational therapy assistant that the resident had low blood pressure, changes in cognition, increased fatigue, nausea, and pale skin. The LPN instructed the assistant to give the resident water and retake the blood pressure, and when the repeat blood pressure was reported, she stated she was no longer concerned and did not assess the resident despite the reported symptoms. The resident remained in the room and was not sent to the ED as ordered. A subsequent progress note documented that the resident died early the next morning. The Director of Nursing Services later acknowledged that the nurse who received the critical lab did not write a timely progress note, did not enter the verbal order to transport the resident to the ED, did not act on the transport order, and did not document the provider’s verbal order at the time of the incident. The deficiency also includes two separate medication error issues. One resident admitted with sepsis had a physician order for Cefazolin every eight hours, but the order was transcribed as ceftriaxone, and the resident received the wrong antibiotic 11 times, as documented in the MAR and a facility report of incident. Another resident with PTSD had a physician order for quetiapine 100 mg in the morning and at bedtime; during a care conference for gradual dose reduction, it was noted that the resident had been administered more quetiapine than ordered. The orders were changed to 300 mg at bedtime with discontinuation of the 100 mg morning dose, but the morning dose was not discontinued, resulting in continued administration beyond the revised order. The DNS acknowledged the medication administration errors for both residents.
Failure to Administer Insulin per Physician Orders During Resident Absence
Penalty
Summary
The facility failed to follow physician orders for a resident with diabetes and diabetic kidney complications who was admitted in July 2025. Physician orders dated September 2025 directed staff to administer insulin glargine twice daily for diabetes management. Documentation showed that during five morning medication administrations, the resident was absent from the facility without her/his medications. Staff interviews revealed that the resident left the facility before the morning shift began to attend dialysis and returned in the afternoon. The LPN responsible for the morning shift was unaware of whether the night nurse had administered the insulin or if it was sent with the resident to dialysis. The regional nurse confirmed that physician involvement would be expected in developing a clinical plan for insulin administration while the resident was out of the facility.
Failure to Provide Ordered Oxygen Therapy
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for a resident with chronic respiratory failure. The resident was admitted with a physician's order for continuous oxygen at three liters per minute every shift. On one occasion, a physical therapist assistant entered the resident's room and found the oxygen concentrator was not turned on, resulting in the resident's oxygen saturation dropping to 88 percent. After oxygen was administered, the saturation increased to 93 percent. Staff confirmed that the oxygen concentrator had been off when the resident was found, and the administrator acknowledged that staff were expected to follow physician orders for oxygen use. A public complaint was also received alleging that after the resident was returned to their room, staff did not turn on the oxygen concentrator, and it remained off for several hours until discovered by staff.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report does not specify the exact actions or inactions, nor does it provide details about the residents or staff involved, but it clearly states the absence or inadequacy of an infection prevention and control program.
Failure to Maintain Sufficient CNA Staffing
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of every resident, as required. Review of the Direct Care Staffing Daily Report forms for the period from 7/1/25 through 8/3/25 showed that the facility did not have sufficient CNA staffing on six out of thirty-three days. Specifically, insufficient staffing was noted on the day shift for 7/3/25, the evening shift for 7/4/25, and the night shifts for 7/22/25, 7/5/25, 7/8/25, and 7/19/25. This was confirmed by the Regional Staffing Coordinator during an interview on 5/9/25 at 9:09 AM. Residents were placed at risk for unmet needs due to these staffing shortages. No additional details about individual residents or their medical conditions were provided in the report.
Improper Hand Hygiene Observed During Food Service
Penalty
Summary
Staff failed to properly follow hand hygiene protocols during food preparation and service. Specifically, one dietary aide was observed handling a plate cover that had been placed on a dirty dish counter and then returning to plating lunches without washing his hands. On multiple occasions, staff washed their hands but then either turned off the faucet with wet hands or used the same paper towel to both turn off the faucet and dry their hands, which is not in accordance with proper hand washing procedures. The corporate dietary manager confirmed that the observed staff did not follow the correct hand washing procedure during lunch preparation. These actions were directly observed by surveyors and involved two of three kitchen staff, placing residents at risk for foodborne illness due to improper hand hygiene during food service.
Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
A resident admitted with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and muscle weakness was found to have two inhalers at their bedside without documentation of an assessment for safe self-administration of medication. The resident stated that staff were aware of the inhalers in the room and explained that they used the inhaler during COPD flare-ups, expressing concern about delays if they had to wait for staff assistance. Observation confirmed the presence of both inhalers, and staff interviews revealed uncertainty regarding whether the resident was authorized or assessed to self-administer these medications. A CNA reported the presence of the inhalers to the charge nurse but was unaware of any authorization for self-administration. An LPN confirmed knowledge of the requirement for assessment prior to residents keeping medications at the bedside but did not know if this had occurred for the resident in question. The LPN checked the inhalers and left them in the room, stating he would follow up with administration. The Corporate Director of Nursing Services later acknowledged that the resident did not have an order or assessment for self-administration of inhalers.
Failure to Notify Physician of Change in Resident Condition
Penalty
Summary
Facility staff failed to notify a physician of a change in condition for a resident who was admitted with acute kidney disease and was cognitively intact, as indicated by a BIMS score of 14. On the evening in question, nursing notes documented that the resident developed draining blisters on the chest and reported sensations of burning and being stabbed with needles. The resident was subsequently sent to the emergency department. However, a review of the medical record confirmed that the physician was not notified of these changes in the resident's condition prior to the transfer. This lack of physician notification was acknowledged by the Corporate DNS, DON, and Regional nurse during interviews.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Prevent and Report Verbal Abuse Among Residents
Penalty
Summary
The facility failed to prevent and properly report verbal abuse for two residents who were subjected to repeated racial and discriminatory remarks by other residents. One resident, admitted with respiratory failure and cognitively intact, experienced multiple incidents where another resident made derogatory comments about their language and ethnicity in the presence of staff, family, and other residents. Despite these repeated outbursts, staff responses were limited to apologizing to the affected resident and advising them to avoid the perpetrator or ignore the comments, rather than intervening or addressing the abusive behavior. No documentation of an internal investigation or facility-reported incident was provided for these events, and staff did not report the incidents to the appropriate authorities as required by facility policy. Another resident, with dementia and anxiety, reported being subjected to a racial slur by a former roommate following an argument. This incident led the resident to avoid communal areas due to discomfort and fear of further interaction. Again, the facility did not provide any documentation of an investigation or facility-reported incident related to this verbal abuse. Interviews with facility leadership confirmed awareness of the incidents but revealed no evidence of timely reporting or investigation, as required by the facility's abuse policy.
Failure to Provide Bed Hold Policy Notification During Hospital Transfers
Penalty
Summary
The facility failed to inform two cognitively intact residents of the Bed Hold Policy when they were transferred to the hospital. For one resident with Type 2 diabetes mellitus, staff responded to a medical emergency involving a fall and low blood glucose, resulting in the resident being transported to the hospital by EMS. There was no documentation that the resident or their representative received a copy of the Bed Hold Policy or written notice of transfer, as required by facility policy. Staff interviews confirmed that the process was not followed, with some staff stating that only verbal offers were made or that paperwork was not provided at the time of transfer. A second resident, admitted with acute kidney disease, was also transferred to the hospital after developing severe symptoms, including blisters and pain. Review of the clinical record found no documentation that the resident was informed of the Bed Hold Policy or received written notice of transfer. Facility leadership confirmed that the required notices were not given in either case, and staff acknowledged the oversight in providing discharge and treatment notices.
Failure to Complete Ordered Laboratory Testing
Penalty
Summary
The facility failed to follow physician orders for laboratory testing for a resident admitted with a history of stroke, fluency disorder, and depression. A psychiatric admission progress note documented a new order for a Complete Blood Count (CBC) lab for the resident. However, review of the resident's medical record showed no evidence that the CBC lab was obtained. During an interview, the Director of Nursing Services (DNS) confirmed she was not aware of the laboratory order and acknowledged that it was not completed.
Failure to Complete Required Neurological Checks After Unwitnessed Fall
Penalty
Summary
A deficiency occurred when staff failed to properly monitor a resident after an unwitnessed fall. The resident, who had a history of stroke, was found on the floor next to their bed after their roommate activated the call light. The resident was unable to recall how they ended up on the floor or whether they struck their head. Facility protocol required neurological checks to be performed at specific intervals following an unwitnessed fall, but only one neurological assessment was documented in the clinical record. Interviews with staff confirmed that neurological assessments were expected to be completed and documented, but this was not done for the resident involved.
Failure to Keep Refuse Container Covered Due to Broken Mechanism
Penalty
Summary
During an observation of the facility's outdoor trash and recycling area, the exterior refuse container was found with its lid open, leaving a gap of approximately twelve to fifteen inches between the lid and the body of the dumpster. The Dietary Manager confirmed that staff did not always close the dumpster because it was difficult to close, and when attempting to close it, was unable to do so due to a broken cranking mechanism. This failure to keep the refuse container covered was directly observed and acknowledged by staff during the walkthrough.
Staffing Deficiencies Lead to Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of residents, as evidenced by multiple accounts from residents, staff, and witnesses. Resident 17, who was admitted with paraplegia and a pressure ulcer, reported that during August and September, there were instances when their call light was activated for hours without response, particularly on weekends when staffing was critically low. Witnesses and staff corroborated these claims, noting that the facility was often short-staffed, leading to unmet needs such as missed showers and increased falls. Resident 22, who had a history of falling, dementia, and anxiety, experienced an incontinent episode due to delayed staff assistance, as the facility was short-staffed. Documentation revealed that the facility did not meet state minimum CNA staffing requirements on certain shifts, contributing to the resident's unmet needs. Witnesses confirmed that the resident had to wait for assistance, which led to the incontinent episode. Staff members consistently reported that the facility was short-staffed, leading to negative outcomes for residents, including increased falls and missed care tasks. Several staff members, including CNAs and agency staff, described being assigned an excessive number of residents, which made it difficult to provide adequate care. The lack of sufficient staffing resulted in long call light wait times, incomplete care tasks, and staff burnout, further exacerbating the situation.
Inaccurate Staffing Information Posting
Penalty
Summary
The facility failed to post accurate and complete staffing information, as evidenced by multiple discrepancies in the Direct Care Staff Daily Reports (DCSDR) and Daily Punches (staff time sheets) over the months of July and August 2024. Specific issues included missing census documentation for various shifts on several days, incomplete DCSDR entries, and inconsistencies between the reported hours worked by Certified Nursing Assistants (CNAs) and the actual hours documented in the time sheets. For instance, on 8/15/24, the DCSDR indicated that seven CNAs worked a total of 56 hours, whereas the time sheets showed only 39.5 hours worked by six CNAs. Similar discrepancies were noted on 8/28/24. Further observations in October 2024 revealed that the DCSDR for 10/8/24 was not posted, and on 10/9/24, the DCSDR lacked census documentation for the day shift. During an interview on 10/16/24, the facility's Administrator, Director of Nursing Services (DNS), and Regional Nurse Consultant acknowledged the presence of new nursing staff and the need for additional education on completing the DCSDR sheets. These deficiencies in maintaining accurate staffing records placed residents at risk for incomplete and inaccurate staffing information.
Verbal Abuse Incident Involving CNA and Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse by staff. The incident involved a resident who was admitted with diagnoses including a chronic ulcer and a sacrum fracture. The resident reported that a CNA entered their room loudly, waking them from a deep sleep, and continued to raise his voice during interactions. The CNA allegedly called the resident a liar multiple times and refused to leave the room despite the resident's requests. The resident felt verbally abused and reported the incident to the admissions coordinator, who witnessed the CNA apologizing but still yelling at the resident. The investigation revealed that the resident was cognitively intact, with a BIMS score of 15, and exhibited no behavioral symptoms in the days leading up to the incident. The CNA admitted to calling the resident a liar but denied yelling. The facility's investigation concluded that the allegations were unsubstantiated, although it was noted that the CNA should have left the room and reported the resident's behavior to a charge nurse when the situation escalated.
Delayed Reporting of Investigations to State Agency
Penalty
Summary
The facility failed to report investigations timely to the State Survey Agency for three residents reviewed for medications, abuse, and neglect. Resident 12, admitted with anxiety and a leg fracture, had an incident reported to the State Agency on the same day it was discovered, but the investigation report was sent late. Staff confirmed that the delay was due to a misunderstanding by the Director of Nursing Services (DNS) who thought she had emailed the investigation on time. Resident 19, admitted with pain and surgical aftercare, had an incident reported five days after it occurred, as the facility was only made aware of it on that day. The investigation report was also sent late due to difficulties in contacting a witness. Resident 20, admitted with a leg fracture, had an incident reported on the day it occurred, but the investigation report was again sent late. Staff confirmed the delay in sending the investigation report to the State Agency.
Failure to Conduct Timely and Thorough Investigations
Penalty
Summary
The facility failed to conduct timely or thorough investigations for three residents, leading to potential risks. Resident 11, admitted with arthritis, experienced an unwitnessed fall on 6/3/24, but the investigation was not completed until 6/26/24, which was confirmed as late by the facility's staff. Resident 19, admitted with pain and surgical aftercare, filed a grievance on 6/24/24 regarding rough care by an agency LPN during wound treatment on 6/19/24. The investigation, conducted from 6/24/24 to 7/1/24, did not include witness statements or contact with the LPN involved, and failed to address Resident 19's pain medication, as confirmed by facility staff. Resident 20, admitted with a leg fracture, was found unresponsive after medication administration on 9/27/24. An investigation from 9/27/24 to 10/10/24 revealed a family member's concern about sedation and abuse, but the investigation did not reconcile the resident's medications or review narcotic administration. Facility staff focused on communication with the emergency department rather than the medication issue. The investigation also erroneously included information about an unrelated resident altercation. These deficiencies were confirmed by facility staff, indicating a lack of thoroughness in addressing the medication and care concerns.
Inappropriate Conduct by CNA with Resident
Penalty
Summary
Facility staff failed to adhere to professional standards of practice in the care of a resident, identified as Resident 12, who was admitted with a leg fracture. The deficiency involved Staff 7, a CNA, who engaged in behavior that was deemed inappropriate and unprofessional. Staff 7 was reported to have spent excessive time with Resident 12, massaged her/his hip in a manner that felt inappropriate, and provided personal contact information to the resident, suggesting he could be her/his personal caregiver post-discharge. These actions were reported by Resident 12, who felt uncomfortable with the level of personal attention and the nature of the interactions, although she/he did not categorize it as sexual abuse. The situation was further corroborated by a family member, Witness 7, who confirmed that Staff 7 had offered his contact information for future caregiving services and applied cream to Resident 12 without a request. Staff 36, a Speech Therapist, documented the incident by photographing the contact information and reporting it to Staff 35, the Director of Rehabilitation, who then informed the facility's Administrator. The facility's administration confirmed that Staff 7's actions were against facility policy and constituted a conflict of interest, as it involved soliciting work outside the facility. Despite the resident's modesty and lack of feeling of inappropriate physical contact, the interactions were considered unprofessional and inappropriate by the facility's standards.
Failure to Assist Residents with ADLs Due to Staffing Issues
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents, leading to unmet needs. Resident 21, who was admitted with dementia and anxiety, required substantial to maximal assistance with bathing. Despite this, there were multiple instances where Resident 21 did not receive the required bathing assistance, going up to 13 days without a bath. Documentation inconsistencies were noted, with some records indicating refusal without proper resident signatures, and staff misreporting environmental limitations as resident refusals due to a lack of staff. Resident 22, admitted with a history of falling, dementia, and anxiety, was dependent on staff for toilet use and transferring. The facility was short-staffed, leading to delays in assistance and resulting in incontinent episodes for Resident 22, who was otherwise occasionally continent. The facility's staffing levels did not meet state minimum requirements, contributing to the inability to provide timely assistance, as confirmed by staff and a complainant.
Inaccurate Medication Records for Controlled Substances
Penalty
Summary
The facility failed to ensure that resident records related to controlled medications were complete and accurate, specifically for a resident who was admitted with a leg fracture. The review of the Narcotic Logbook (NLB) for September 2024 revealed discrepancies in the administration of oxycodone, a narcotic pain medication, for this resident. The resident was prescribed oxycodone in various dosages and frequencies, but the records showed multiple instances where the resident was administered two tablets instead of the one tablet as ordered by the physician. Additionally, the resident received the medication more frequently than prescribed on several occasions. Further review of the Medication Administration Record (MAR) indicated inconsistencies with the NLB, including missing documentation for certain prescribed dosages and frequencies of oxycodone. The facility staff, including the Administrator, Director of Nursing Services (DNS), and Regional Nurse Consultant, acknowledged that the resident received medications as ordered by the physician, but staff continued to use the same page in the NLB even after changes in the resident's physician orders. This practice led to incomplete and inaccurate medication records, placing residents at risk for medication errors.
Failure to Address Resident Dining Concerns
Penalty
Summary
The facility failed to respond timely to resident concerns related to dining, as evidenced by the Resident Council minutes from November 2023 to March 2024. Residents expressed concerns about outdated 'always available' menus in their rooms and requested weekly menus to make meal choices. Despite the facility's initial responses, these issues were not resolved. By March 2024, the Dietary Manager and Registered Dietitian acknowledged that printed menus were not available due to other dining priorities. The Administrator and Regional Director of Social Services and Activities also acknowledged that residents' concerns should have been addressed in subsequent meetings, but they were not.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to have a system in place to deliver mail on Saturdays, which was identified during a Resident Council meeting. A resident stated that for a long time, residents did not receive mail on Saturdays. The Activity Director confirmed that mail delivery on Saturdays ceased approximately a month ago due to the absence of an activity assistant, who previously handled this task.
Failure to Make Survey Results Readily Available
Penalty
Summary
The facility failed to ensure past survey results were readily available for residents and visitors. During a resident council interview, residents stated they did not know where the past survey results were kept and believed they were at the nurses' station. Upon observation, the past survey results were found in a clear wall-mounted bin labeled 'Requests, concerns, and suggestions,' but were obscured from view by unrelated facility forms such as information regarding rules for visits and grievance forms. The Administrator confirmed this location as the usual place for keeping the survey results.
Improper Waste Containment in Garbage Storage Area
Penalty
Summary
The facility failed to ensure waste was properly contained in the garbage storage area, which was observed to be dirty and disorganized. On multiple occasions, the garbage container lid was found open, and the surrounding area was littered with broken doors, unused resident commodes, dirty disposable gloves, miscellaneous wood pieces, and outdoor debris. Staff 42 (Maintenance Director) acknowledged the state of the garbage area and cited a lack of time since February 2024 to clean it. Staff 41 (CNA) confirmed that the area frequently had debris, including dirty gloves. Staff 31 (Dietary Manager) was unaware of any requirement to monitor the garbage area but agreed it should be kept clean.
Failure to Address Resident Choice for Dining
Penalty
Summary
The facility failed to address resident choice for dining, affecting five of the 22 sampled residents. Observations revealed that daily menus were posted on the first and second floors, but no weekly menus were available. Several residents expressed dissatisfaction with the lack of meal choices and the new system implemented by the facility, which required a three-hour notice for menu changes. Residents who were bedridden found it difficult to access the posted menus, and some reported that staff no longer discussed daily menu options with them. One resident mentioned that the option to choose between two meal options was no longer available, and another resident, new to the facility, had no choices related to daily meal options and was dissatisfied with the provided meal. Staff interviews further confirmed the deficiency. An LPN was unaware of the accurate menu information and acknowledged that residents frequently voiced concerns about the removal of menu choices. The Dietary Manager and Registered Dietitian admitted that there were no printed menus for residents, making it difficult for them to understand their meal options. Additionally, the Administrator and Northern Regional Director of Operations confirmed that menu information was not included in new admissions packets and acknowledged the need for printed menus to be distributed and placed in every resident room.
Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and care to prevent accidents for four residents. Resident 4, who had dysphagia, was left unsupervised during meals despite needing assistance and monitoring to prevent choking. The care plan was not updated, and staff did not follow the necessary interventions, leading to the resident being at risk while eating alone in their room for 20 minutes without supervision. Resident 220, with severe cognitive impairment, eloped from the facility twice in one evening. The first incident was witnessed by staff, and the second was unwitnessed. Despite being found on the facility grounds, the investigation revealed multiple lapses in supervision and failure to secure the facility's perimeter, allowing the resident to leave the building and access unsafe areas. Resident 22, who was at risk for falls, experienced two unwitnessed falls. The investigations into these falls were incomplete, failing to document critical details such as the duration the call light was activated and the last time the resident was visualized. Additionally, the care plan was not followed, and no new interventions were implemented to prevent further falls. Resident 35, who had a history of noncompliance with the facility's smoking policy, was assessed as an unsupervised smoker despite having dexterity problems and a history of hiding smoking materials. The resident was observed smoking unsupervised and improperly disposing of cigarette butts, indicating a failure to reassess and update the smoking risk assessment accurately.
Inadequate Staffing Leading to Prolonged Call Light Wait Times and Incontinence
Penalty
Summary
The facility failed to have adequate staff available to meet the needs of residents in a timely manner, as evidenced by multiple instances of prolonged call light wait times and residents experiencing incontinence due to delays in assistance. Resident 10, who was admitted in 2020 with diagnoses including difficulty in walking and a stroke, reported call light wait times of over 15 minutes, and sometimes over 30 minutes, leading to multiple incontinent episodes. Documentation confirmed Resident 10 was incontinent on two occasions in March 2024. Staff interviews corroborated these findings, with one CNA stating she was often assigned 12 to 13 residents and had to prioritize tasks, resulting in residents waiting 20 to 30 minutes for assistance and being found soaked in urine or soiled with feces at the start of shifts. Resident Council Minutes from November 2023 indicated that staff would deactivate call lights without addressing residents' needs, with wait times as long as an hour. Multiple residents and a family member reported call light wait times ranging from 20 minutes to over an hour, with some residents left in the restroom or on a bedside commode for extended periods. One resident reported not receiving showers due to staff shortages, and another stated they had to clean themselves after an incontinent episode due to the lack of staff assistance. Staff interviews further highlighted the staffing issues, with reports of insufficient CNA staff on day and evening shifts, difficulty in finding assistance for two-person tasks, and incomplete care due to short staffing. One LPN described a situation where only one nurse was available to handle multiple tasks, including medication passes, admissions, wound care, and IV treatments. Another staff member noted that residents were not receiving showers and were left on commodes for extended periods due to staffing shortages. The facility acknowledged the ongoing issue and stated they were actively hiring staff.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to staff a registered nurse (RN) for 8 consecutive hours per day, 7 days per week, for 15 out of 123 days reviewed. This deficiency was identified through a review of the Direct Care Staff Daily Reports for the periods of 5/1/23 through 5/31/23, 6/1/23 through 6/31/23, 8/1/23 through 8/31/23, and 2/17/24 through 3/17/24. Specifically, the facility lacked RN coverage on the following days: 5/18/23, 5/24/23, 5/30/23, 5/31/23, 6/6/23, 8/1/23, 8/2/23, 8/9/23, 8/15/23, 2/18/24, 2/27/24, 3/3/24, 3/5/24, 3/10/24, and 3/12/24. This placed residents at risk for unmet assessment needs. During an interview on 3/22/24, the facility's administrative and regional staff acknowledged the ongoing issue and stated that they were actively hiring staff to address the deficiency.
Failure to Complete Annual Performance Reviews for CNA Staff
Penalty
Summary
The facility failed to ensure that annual performance reviews were completed for five Certified Nursing Assistants (CNAs) who were sampled for staffing. Specifically, the facility was unable to provide performance reviews for CNA staff members hired on various dates ranging from December 2013 to December 2021. This deficiency was confirmed by the Administrator, who acknowledged the absence of performance reviews for these staff members. The lack of documented performance reviews placed residents at risk for receiving care from potentially incompetent staff.
Failure to Submit Mandatory Staffing Information
Penalty
Summary
The facility failed to submit mandatory staffing information based on payroll data and other verifiable and auditable data as required by CMS. This deficiency was identified during a review of the Payroll Based Journal Staffing Data for fiscal year, quarter two, 2023, which indicated that the facility did not submit the required data for the quarter. During an interview, the Administrator, DNS, Regional Director of Social Services and Activities, Regional Director of Clinical, and Northern Regional Director of Operations stated that the corporate office was responsible for submitting the data and they were unaware that it had not been submitted.
Infection Control Deficiencies in Catheter and Linen Handling
Penalty
Summary
The facility failed to follow infection control standards for a resident with a catheter and for handling dirty linens. Resident 4, who was admitted with prostate cancer and had a catheter due to urinary retention, was observed with the catheter bag improperly attached to a small garbage can and later with the catheter bag in contact with the floor while in the dining room. Staff 12, an agency CNA, admitted to attaching the catheter bag to the garbage can due to the bed's low position and lack of knowledge on proper attachment. Facility leadership was informed of these observations but did not take immediate corrective action. Additionally, a CNA was observed carrying dirty linens in her hands instead of using disposable bags, which were reportedly not available since December 2023. Despite the presence of dispensers filled with disposable bags in resident bathrooms, the CNA and a unit manager were unaware of their availability. The unit manager confirmed observing staff handling dirty linens without disposable bags but did not address the issue with the CNA staff. This failure to use proper infection control measures for handling dirty linens further contributed to the deficiency.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure residents were assessed for self-administration of medications, affecting two residents. Resident 13, diagnosed with kidney disease, expressed a desire to self-administer a phosphorous binder but was not assessed for this capability. Despite being cognitively intact and having communicated this wish to staff, no assessment was conducted. Additionally, staff failed to administer the medication with meals as required, instead providing it after meals, which was not in line with the prescribed regimen. Resident 47, diagnosed with diabetes, was found to have a tube of medicated cream on their bedside table, which they applied as needed. However, there was no record of an assessment for self-administration of this medication in the resident's clinical record. Staff confirmed that an assessment, an order for self-administration, a care plan, and secure storage of the medication were required but had not been completed for this resident.
Failure to Address Resident's Missing Items Timely
Penalty
Summary
The facility failed to ensure a resident's missing items were addressed timely for a resident admitted with a diagnosis of heart disease. Approximately one month prior, the resident's family member reported a missing favorite shirt to the laundry staff, and two weeks later, a new blanket went missing. Despite the staff's assurance to look for the items, no resolution was provided. The Regional Director of Clinical confirmed that no missing item forms were filled out for the resident. The Laundry Manager acknowledged receiving a hand-written note about the missing blanket but did not fill out a grievance form and could no longer locate the note. The Northern Regional Director of Operations stated that missing items should be documented on a form and a response provided within seven days, which was not done in this case.
Failure to Monitor and Assess Continued Use of Physical Restraint
Penalty
Summary
The facility failed to monitor and assess the continued use of a physical restraint for Resident 4, who was admitted in 2022 with diagnoses including muscle wasting and atrophy. The care plan revised on 8/14/23 indicated that Resident 4 was an elopement risk due to dementia and wandering behavior, and interventions included the use of a Wander Guard on the right wrist. However, documentation from 3/1/24 through 3/5/24 showed that the device was not verified for placement four times out of 15 opportunities, and there was no documentation of device placement verification from 3/13/24 through 3/22/24. Additionally, the order to test the Wander Guard weekly was discontinued on 3/11/24, and a 3/20/24 Nursing Note indicated that Resident 4 no longer attempted to elope and requested orders to discontinue the Wander Guard. Despite this, the Wander Guard was still in place on 3/18/24 and 3/22/24, and it triggered an alarm when a staff member attempted to take Resident 4 out of the facility for an appointment on 3/22/24. Interviews and observations revealed inconsistencies in the assessment and monitoring of the Wander Guard. On 3/21/24, an LPN Unit Manager stated that Resident 4 was not a wander risk, yet the Wander Guard was still in place the following day. The lack of consistent documentation and assessment placed Resident 4 at risk for potential abuse or neglect, as the continued use of the physical restraint was not adequately justified or monitored. This deficiency highlights the facility's failure to ensure that each resident is free from the use of physical restraints unless needed for medical treatment.
Failure to Conduct Timely Significant Change MDS Assessment for Hospice Resident
Penalty
Summary
The facility failed to conduct a Significant Change Minimum Data Set (MDS) assessment within the required timeframe for a resident who was reviewed for hospice care. The resident, who was admitted to the facility in 2024 with a diagnosis of heart disease, was approved and certified for hospice services by a physician on February 3, 2024. However, a review of the resident's clinical record revealed that a significant change MDS was not completed within 14 days after the resident was admitted to hospice. On March 20, 2024, the MDS Coordinator acknowledged that the significant change MDS was not conducted after the resident was admitted to hospice.
Failure to Revise Care Plans for Dialysis, Hospice, and Pain Management
Penalty
Summary
The facility failed to ensure care plans were revised for three residents reviewed for dialysis, hospice, and pain management. Resident 13, who was admitted with kidney failure, had a change in dialysis start times that was not updated in the care plan. Despite the resident's dialysis times changing to an earlier schedule, the care plan still reflected the old times, and staff acknowledged the care plan was not updated accordingly. Resident 22, admitted with heart disease and later certified for hospice services, had a care plan that did not reflect the hospice admission, including the name of the hospice agency, the resident's advance directive status, and the plan for the resident to remain at the facility. Staff failed to communicate these changes, resulting in an outdated care plan that did not align with the resident's current needs and services provided by hospice. Resident 47, admitted with diabetes, experienced increased pain due to hemorrhoids, which was documented in progress notes but not updated in the care plan. Despite multiple reports of pain and new orders for treatment, the care plan did not reflect the resident's ongoing pain management needs. Staff acknowledged the oversight, indicating a lack of communication and follow-through in updating the care plan to address the resident's pain effectively.
Failure to Provide Elbow Braces for Resident with Contractures
Penalty
Summary
The facility failed to provide splints to reduce contractures for a resident with diagnoses including contractures of the left and right elbows. The resident's care plan indicated the need for elbow braces during the day for six hours, but a quarterly MDS revealed no splint or brace was provided during a seven-day review period. The Kardex for CNAs had no reference to the resident's elbow braces. Observations and interviews revealed that the resident's elbow braces were offered inconsistently, and staff were unaware of the need for the braces. The resident reported that the braces were last applied three days prior and that staff did not know how to correctly apply them. The LPN-Unit Manager acknowledged the inconsistency and the need for the braces to be included in the Kardex for CNAs.
Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to provide appropriate catheter care for a resident with a suprapubic catheter, leading to an increased risk of infections. The resident, who was admitted with diagnoses including quadriplegia and bladder dysfunction, had a history of UTIs related to a chronic indwelling catheter. Despite a care plan revision and a urology clinic note indicating the need for a follow-up appointment and catheter change, the facility did not schedule the necessary follow-up appointment. Additionally, when the resident was eventually scheduled for a catheter change, the facility lacked the appropriate supplies to perform the procedure, further delaying the necessary care. On multiple occasions, staff acknowledged the oversight in scheduling the follow-up urology appointment and the lack of appropriate supplies to change the suprapubic catheter. The resident was observed at the nurses' station awaiting a urology appointment, which was later canceled because the facility was informed that the catheter change could be done on-site. However, the facility was unable to perform the procedure due to the unavailability of the correct catheter size, and management was aware of the situation but still waiting for the supplies to be delivered.
Failure to Maintain Nutritional Parameters for Resident
Penalty
Summary
The facility failed to maintain healthy nutritional parameters for Resident 4, who was diagnosed with dysphagia and required specific dietary interventions. The care plan for Resident 4 included supervision and assistance during meals, the use of a teaspoon for eating, and the avoidance of straws. However, observations revealed that Resident 4 was left unsupervised for 20 minutes while eating breakfast, and there was inconsistency in the care plan regarding the use of straws. Additionally, the resident's nutritional supplements were discontinued without proper documentation of refusals, and there was a lack of clarity in physician orders after the resident's readmission. Staff interviews indicated that the care plan was not updated, and staff relied on verbal reports rather than checking the care plan. The MDS Coordinator admitted to missing the inconsistency in the care plan, and the LPN Unit Manager confirmed that the physician orders were unclear and needed clarification. The Registered Dietitian stated that nutritional supplements were not ordered unless the resident enjoyed them, despite the resident's significant weight loss and nutritional risk factors. This lack of adherence to the care plan and proper documentation placed Resident 4 at risk for further weight loss and compromised nutritional status.
Failure to Implement Pain Management Interventions
Penalty
Summary
The facility failed to ensure pain interventions were implemented to manage a resident's pain effectively. Resident 47, who was admitted in 2023 with a diagnosis of diabetes, reported increased pain due to hemorrhoids starting in December 2023. Despite multiple reports of pain and a new order for hemorrhoid treatment, the resident's care plan was not updated to include pain management for hemorrhoids. Additionally, the facility did not provide the prescribed witch hazel pads or a specialized cushion in a timely manner, leading to the resident experiencing ongoing pain and decreased activity levels. Staff interviews revealed that the MDS Coordinator was not informed of the resident's pain, preventing updates to the care plan. The LPN Unit Manager and other staff members acknowledged the lack of communication and the unavailability of the appropriate witch hazel pads, which caused further discomfort to the resident. The Director of Therapy Services was also unaware of the order for a specialized cushion until much later, delaying its provision. These lapses in communication and failure to implement prescribed interventions resulted in the resident's continued pain and inability to participate in daily activities.
Failure to Address Pharmacy Recommendations
Penalty
Summary
The facility failed to address pharmacy recommendations for a resident reviewed for medications. The resident, admitted in 2023 with diagnoses including arthritis and anxiety, had a pharmacy review on 12/25/23 that recommended labs be obtained to evaluate several medications. However, there was no evidence in the clinical record that the labs were obtained. This was confirmed by the Staff Development Coordinator on 3/21/24, indicating that the labs were not obtained timely.
Failure to Obtain Routine Labs for Medication Monitoring
Penalty
Summary
The facility failed to obtain routine labs to monitor the effectiveness of medications for one resident. A pharmacy review on 12/25/23 identified the need for routine labs to evaluate the resident's medications for high cholesterol, diabetes, vitamin D, B12 deficiencies, sodium, and potassium levels. Another pharmacy review on 2/27/24 noted that the labs were ordered by the physician on 2/19/24, and the facility was requested to obtain a copy of the results for the resident's clinical record. However, there was no evidence in the resident's clinical record that the labs were obtained until 3/1/24. This was confirmed by the Staff Development Coordinator on 3/21/24.
Failure to Monitor Psychotropic Medications
Penalty
Summary
The facility failed to adequately monitor psychotropic medications for a resident diagnosed with bipolar disorder with depression, personality disorder, and agoraphobia with panic disorder. The resident was prescribed Duloxetine for mood disorder with depression and Rexuliti for bipolar disorder. A review of the resident's Medication Administration Records (MARs) for February and March 2024 revealed that staff did not consistently monitor for adverse reactions to these medications. Specifically, in February, out of 87 opportunities, staff failed to monitor on 32 occasions, and in March, out of 57 opportunities, staff failed to monitor on 25 occasions. Interviews with facility staff, including Licensed Practical Nurses (LPNs) and the Staff Development Coordinator, confirmed that they were required to monitor for adverse reactions but did not consistently document this in the resident's medical record. This lack of consistent monitoring and documentation placed the resident at risk for ineffective medication management. The deficiency was identified through both interview and record review, highlighting a significant lapse in the facility's medication monitoring protocols.
Failure to Reschedule Colonoscopy
Penalty
Summary
The facility failed to ensure a resident's colonoscopy was rescheduled after the initial appointment was canceled. Resident 35, admitted in 2021 with a diagnosis of a stroke, experienced abnormal weight loss and had a colonoscopy scheduled to investigate the cause. The colonoscopy was set for 2/15/24, but the resident refused to consume all the preparation medication on 2/14/24, leading to the test's cancellation. The physician was notified, but this was not documented in the resident's clinical record, and there was no follow-up to reschedule the colonoscopy. As of 3/20/24, the colonoscopy had not been rescheduled, placing the resident at risk for delayed treatment.
Failure to Obtain Dental Services for Resident
Penalty
Summary
The facility failed to obtain dental services for a resident diagnosed with malnutrition and quadriplegia. The resident had her/his teeth extracted in May 2023 and required dentures. Despite a care plan revision in March 2024 to coordinate dental care and transportation, the resident continued to request dentures without any update. The social worker attempted to arrange a denture appointment but was waiting for the Director of Nursing Services to discuss the risks and benefits of the procedure with the resident. The Director of Nursing Services acknowledged that follow-up on the resident's request was lacking since February 2024.
Failure to Honor Snack Requests and Provide Adequate Snack Inventory
Penalty
Summary
The facility failed to ensure snack requests were honored and provided for a resident with specific dietary needs and preferences. Resident 2, who had diagnoses including kidney disease and diabetes, requested yogurt and sandwiches as snacks. However, the snack refrigerator on the second floor was observed to be inadequately stocked with these items on multiple occasions. Staff 30, a cook, confirmed that the snack refrigerators were often not stocked with sufficient dairy items, and Staff 31, the Dietary Manager, acknowledged the lack of proper monitoring and stocking of high-demand snacks. This deficiency was further highlighted by the absence of string cheese and yogurt in the snack inventory and the lack of additional inventory sheets for the past three months. Additionally, the Resident Council and Dining Committee minutes indicated that residents had voiced concerns about the insufficient availability of snacks like milk, string cheese, and sandwiches. During a Resident Council meeting, residents reported not receiving requested bedtime snacks and noted the inadequacy of essential snack items. Staff 31 admitted to not using available documentation to monitor snack demands, leading to the failure to meet residents' snack requests. This placed residents at risk for unmet dietary needs and preferences.
Failure to Notify Residents' Representatives of Changes in Condition
Penalty
Summary
The facility failed to notify residents' representatives regarding changes in status or condition for three residents. Resident 41, who was admitted with respiratory failure, tested positive for COVID-19, but the family member was not informed until three days later when she called to check on the resident's status. There was no documentation indicating that the resident did not want the family member to be notified. Staff interviews confirmed that the nurse was responsible for notifying the family member, but this did not occur in a timely manner. Resident 220, admitted with brain damage, had two episodes of wandering on facility property, but the family member was not notified until two days later. The family member expressed concerns about the lack of notification, and staff confirmed the failure to notify. Resident 19, admitted with diabetes, had multiple instances of blood sugar levels exceeding 300, but there was no indication that the physician was notified as required by the physician's orders. Staff interviews confirmed that the physician should have been notified, but this was not documented in the resident's medical record.
Failure to Maintain Homelike Environment and Room Repairs
Penalty
Summary
The facility failed to ensure rooms were homelike and in good repair for two residents. Observations revealed that the footboard of one resident's bed was damaged and mended with electrical tape, with the fractured segment not aligning with the bed. Another resident's room had multiple large gouges exposing the underlying drywall and numerous black vertical streaks on the wall. The resident stated these issues had been present for approximately six to seven months. The Maintenance Director was aware of the broken footboard for roughly two weeks but had not ordered a replacement and was unaware of the gouges and marks on the other resident's wall.
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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