The Creston Health & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Portland, Oregon.
- Location
- 3320 Se Holgate Blvd, Portland, Oregon 97202
- CMS Provider Number
- 385121
- Inspections on file
- 24
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at The Creston Health & Rehabilitation during CMS and state inspections, most recent first.
A facility failed to conduct weekly wound evaluations for a resident with a pressure ulcer, leading to inadequate treatment and increased risk of delayed healing. The resident, with multiple health conditions, was observed in a wheelchair with a pressure ulcer on the right buttock. Weekly evaluations were missed, and those conducted lacked necessary details. Staff noted the resident's preference to remain in the wheelchair, contributing to a Stage 3 ulcer, and despite ordering a cushion, the resident removed it.
The facility failed to assess and respond to significant changes in condition for two residents. One resident, with lung cancer, experienced coffee ground vomit indicative of internal bleeding, but staff did not perform a thorough assessment or notify the physician, leading to the resident's death. Another resident with hypertension and coronary artery disease experienced significant weight gain and edema, but these changes were not reported or assessed, risking fluid overload. These deficiencies highlight a lack of communication and documentation, resulting in substandard care.
A resident did not receive timely PT and OT services after being readmitted to a facility post-hospitalization for sepsis. Despite physician orders, no therapy assessments or treatments were conducted, leading to the resident's physical decline and increased dependency on staff. The resident expressed frustration and a sense of neglect, while staff confirmed the resident's increased need for assistance.
The facility did not ensure residents were fully informed about the binding arbitration agreement upon admission. The Administrator and Bookkeeper were responsible for explaining the Mediation and Arbitration Clause, but the Bookkeeper did not explain the process or obtain signatures. The Administrator admitted there was no clear process for informing residents about these agreements.
The facility failed to implement proper infection control measures, including inadequate cleaning of CBG monitors, delayed enhanced barrier precautions for a resident with a chronic pressure ulcer, improper handling of clean linens, and the absence of a legionella water management plan. These deficiencies were acknowledged by staff and placed residents at risk for cross-contamination.
The facility was found to use undignified language when addressing residents and their equipment, such as referring to a resident with Parkinson's disease as a 'feeder' and posting signs on meal tray carts for 'bibs/cloth protectors and green wipes only.' This language does not align with person-centered care principles and reflects an institutional orientation. The facility administrator acknowledged these findings without providing additional information.
A resident with dementia was found to have an unpersonalized room, despite expressing a desire for decorations. Staff indicated it was the family's responsibility to provide personal items, but no contact was made with the family. Additionally, the facility had several maintenance issues, including missing handrail end caps, torn furniture, and exposed drywall, which were acknowledged by the Administrator and Director of Facility Services.
The facility failed to provide a bed hold policy to two residents upon hospital transfer. One resident, admitted with diabetes, did not receive the policy when discharged to the hospital, despite being cognitively intact. Another resident, with chronic respiratory failure, was transferred multiple times without receiving the policy. Staff confirmed the absence of a written bed hold policy being provided, and the Interim Administrator acknowledged this deficiency.
The facility failed to update care plans for four residents, leading to deficiencies in care. A resident with paralysis developed a deep tissue injury due to pressure from a bedside table, but the care plan was not updated. Another resident had discrepancies in continence status and interventions for leaving the facility. A resident with a history of stroke was observed using straws despite the care plan indicating otherwise. Lastly, a resident with multiple sclerosis had an outdated care plan that did not reflect the discontinuation of a range of motion program.
The facility failed to provide individualized activity programs for four residents, leading to isolation and lack of engagement. Residents with dementia and cognitive impairments were not offered activities matching their preferences, such as reading, music, and group participation. The Activity Director acknowledged limited engagement and documentation of activity involvement.
The facility failed to provide appropriate restorative services and treatment for residents with limited range of motion. A resident with paralysis did not receive reassessed in-bed exercises due to a pressure ulcer, leading to therapy cessation. Another resident with diabetes missed multiple therapy sessions due to lack of assistance, resulting in weakness. A resident with hemiplegia was not comprehensively assessed or monitored for contractures, leading to worsening conditions. Additionally, a resident with multiple sclerosis had their RA program discontinued and not restarted, resulting in worsening contractures.
A facility failed to maintain a medication error rate below 5%, with a rate of 19.23%. A resident with heart disease was prescribed levothyroxine to be taken before meals but received it with other medications after breakfast. An agency LPN administered the medications based on incorrect advice from other staff, contrary to the physician's order and known drug interactions. The DNS acknowledged the error.
The facility failed to secure medication and treatment carts, leaving them unlocked and unattended across multiple halls. On several occasions, carts were observed unlocked, with staff confirming the oversight. This included treatment carts on 1D and 2C, and medication carts on 1B, 1C, and 2C, despite the DNS's expectation for carts to remain locked when unattended.
The facility failed to ensure proper food storage practices, as several undated and unlabeled food items were found in the kitchen's refrigerators. The Dietary Manager and Interim Administrator acknowledged that all food items should have been labeled, dated, and covered, especially opened items, to comply with the US FDA 2022 Food Code.
The facility failed to obtain consents for psychotropic medications for two residents, risking their right to decline such treatments. One resident, admitted with severe malnutrition, was given Sertraline and Trazodone without consent, despite being cognitively intact. Another resident, with anemia and major depressive disorder, was prescribed Celexa without being informed of its risks and benefits, and no consent was obtained. The DNS acknowledged the oversight in both cases.
A resident with diabetes and PTSD expressed a desire to have their bed closer to their spouse's bed for emotional support, but the facility failed to address this preference. Despite being cognitively intact and communicating the request, the beds remained unchanged. The Social Services Coordinator was aware of the request but did not know if it had been assessed, and the DNS was unaware of the request but noted an assessment would be needed for safety.
Two cognitively intact residents in the facility did not have advance directives documented, despite the facility's protocol to review and document such information during care conferences. One resident, admitted with severe malnutrition, expressed a preference against tube feedings but was unsure about the existence of a previous advance directive. Another resident, admitted with diabetes, also lacked documentation of an advance directive. The Social Services Coordinator confirmed that there was no indication that advance directive information was provided to these residents.
A facility failed to notify a resident's emergency contact of their hospitalization. The resident, admitted with diabetes, was hospitalized after experiencing symptoms like vomiting and altered mental status. Despite being cognitively intact, their emergency contact, who had dementia, was not properly informed. Staff confirmed the contact was notified but did not understand the situation, and there was no documentation of notification in the resident's record.
The facility failed to provide necessary NOMNC and SNF ABN notifications to residents, leading to a lack of awareness about their right to appeal and potential financial liabilities. Two residents did not receive the NOMNC when their Medicare Part A benefits ended, and two residents were not given the SNF ABN. This oversight was confirmed by the Social Services Coordinator and acknowledged by the Interim Administrator.
A resident with osteoarthritis and lower back pain expressed concerns about a caregiver to an RN and an LPN, requesting a grievance form. The Interim Administrator was unaware of the concerns, and a grievance form was not completed promptly, despite the RN informing the Social Services Director. This failure to address the grievance led to a deficiency.
The facility inaccurately assessed residents' needs in communication, dental, and transfers. A resident with Parkinson's disease was noted to have communication difficulties not reflected in their MDS. Another resident required a hoyer lift for transfers, contrary to their MDS assessment. Additionally, a resident with severe malnutrition was observed to have no teeth, yet their MDS did not indicate dental issues. Staff acknowledged these assessment inaccuracies.
A resident with severe cognitive impairment and hearing difficulties did not have access to communication tools as outlined in their care plan. Despite the resident's admission of hearing challenges and the care plan's inclusion of a dry erase board and alternative communication tools, these were not present in the resident's room. Staff reported difficulties in communication, with no tools being utilized to aid interactions.
A resident with dementia, requiring assistance with personal hygiene, was observed with significant chin hairs over several days. Despite expressing a desire to have them shaved and the Kardex directing staff to assist, the resident remained unshaven. Staff acknowledged the need for assistance, but the expectation for scheduled shaving was not met, resulting in a deficiency.
A resident with depression and adjustment disorder experienced worsening symptoms, as indicated by increasing PHQ-9 scores. Despite this, the care plan was not updated with new interventions. The resident felt neglected, spending most of the time in bed. The Social Services Director acknowledged a lack of proper reporting to the resident care manager, who was unaware of the resident's condition.
Two residents in an LTC facility did not receive prescribed medications due to unavailability and lack of communication. One resident missed doses of Vitamin B12, folic acid, and Invokana, while another did not receive pravastatin and oxycodone. Staff failed to notify the charge nurse or contact the pharmacy and provider, leading to deficiencies in pharmaceutical services.
A resident was prescribed trazodone and sertraline without proper monitoring for side effects, despite a care plan highlighting potential risks such as drowsiness and increased falls. The DNS confirmed that staff failed to document side effect monitoring on the MARs.
A resident, admitted with diabetes and cognitively intact, had all their teeth extracted but was not scheduled for a follow-up dental exam. Despite expressing a desire for dentures, the resident was not on the list for an upcoming dental appointment. The Social Services Director confirmed the oversight, and the dentist noted that gums typically heal in about eight weeks, allowing the denture process to start.
The facility failed to prevent accident hazards for three residents. A resident requiring a two-person transfer was moved by one staff, causing fear and near-fall. Another resident had unsecured wound care medications in their room, posing a hazard. A third resident, at risk for falls, was found in a bed not in the low position and without required fall mats, leading to their legs hanging off the bed.
A resident was discharged from a facility without complete discharge instructions, including wound care and follow-up for a possible infection. The resident, who had a hip fracture and other health issues, was re-admitted to the hospital with a post-operative wound infection. The facility failed to remove surgical staples or arrange a follow-up appointment with the orthopedic surgeon, contributing to the resident's condition worsening at home.
A resident with diabetes and kidney disease received incorrect oxygen administration, contrary to physician orders, at a facility. The resident was supposed to receive oxygen via nasal cannula at 3 lpm but was given incorrect flow rates and an oxygen face mask instead. This led to difficulty breathing and low oxygen saturation, resulting in the resident's transfer to the hospital.
A resident with diabetes and kidney disease experienced improper oxygen administration due to staff's lack of knowledge about the correct flow rate for a face mask. The resident's oxygen saturation was below normal, and staff interviews revealed they were unaware of the correct procedures and had not received adequate training. This led to the resident's condition worsening and a request for hospital transfer.
A resident's wheelchair was repeatedly observed to be dirty, with crumbs and brown smudges, despite facility records indicating it was cleaned. The resident, with multiple sclerosis and paraplegia, and other residents had expressed concerns about wheelchair cleanliness. Staff confirmed the unclean condition, and an LPN admitted to falsely documenting a cleaning.
Failure to Conduct Weekly Wound Evaluations for Pressure Ulcer
Penalty
Summary
The facility failed to conduct weekly wound evaluations for a resident with a pressure ulcer, which increased the risk of delayed healing and inadequate treatment. The resident, who was admitted with multiple diagnoses including atherosclerosis, diabetes, and chronic heart failure, was observed in an electric wheelchair and had a pressure ulcer on the right buttock. The ulcer was initially identified in a Weekly Skin Evaluation on 1/26/25, but subsequent evaluations were not conducted until 2/16/25, missing the weeks of 2/5/25 and 2/12/25. The evaluations that were conducted on 2/16/25 and 2/23/25 did not include necessary details such as the stage, measurements, or a description of the wound. Staff interviews revealed that the resident preferred to remain in the wheelchair, which contributed to the development of a Stage 3 pressure ulcer. The DNS expected weekly skin assessments to be conducted with proper documentation, including staging and measurements. Despite ordering a wheelchair cushion for the resident, it was noted that the resident removed it and placed it in a manual wheelchair. This lack of consistent and thorough wound assessment and documentation led to the deficiency identified by the surveyors.
Failure to Assess and Respond to Changes in Resident Conditions
Penalty
Summary
The facility failed to adequately assess and respond to a significant change in condition for Resident 89, who was admitted with a diagnosis of lung cancer with metastasis. Despite being a full code, the resident experienced a significant change in condition, including vomiting that resembled coffee grounds, which is indicative of potential internal bleeding. The staff did not perform a thorough assessment, failed to document vital signs, and did not notify the physician of the resident's condition. This lack of action resulted in a delay in treatment, and the resident was found without a pulse or respirations several hours later, ultimately leading to their death. Additionally, the facility did not properly monitor Resident 38, who was admitted with conditions including hypertension, coronary artery disease, and peripheral vascular disease. The resident experienced significant weight gain and edema, but there was no evidence that these changes were reported to the physician or that an assessment was conducted to determine the underlying cause. The resident's edema was not being monitored, and the physician was not notified of the weight gains, which could indicate fluid overload. The deficiencies in both cases highlight a failure to assess, monitor, and document significant changes in residents' conditions, placing all residents at risk for delayed assessments and treatments. The lack of communication and documentation among staff members contributed to these failures, resulting in substandard quality of care.
Removal Plan
- A review of other resident's change of condition that may be affected was completed by the DNS and designated staff. Other residents identified with a change of condition were to have assessments completed and residents' primary care physicians would be notified as appropriate.
- Education for the Nurse and CNA was completed by the assistant DNS. Further education would be completed with every employee (clinical, administrative, social service, activities, housekeeping, dietary and maintenance) to communicate changes in condition. Employees not on shift would be trained prior to starting shift with review of policy and procedure, then signing off on understanding and implementation. Once notified of a change of condition, the nurse would document, complete an assessment, and notify the primary care physician as appropriate.
- Performance Improvement Project for change of condition would be initiated by the DNS or designee to audit 1.) Resident change of condition and 2.) Nurse assessments were completed the day of reported change of condition. The audits would be conducted weekly, then twice a month, and randomly thereafter. Results would be shared with Quality Assurance and Performance Improvement committee until substantial compliance was achieved.
Failure to Provide Timely Rehabilitative Services
Penalty
Summary
The facility failed to provide timely specialized rehabilitative services, specifically physical therapy (PT) and occupational therapy (OT), to a resident who was readmitted to the facility after a hospital stay for sepsis. The resident, who had a history of falls, was supposed to continue with functional mobility and activities of daily living (ADL) levels established in the hospital until assessed by PT. However, there was no evidence in the resident's clinical record indicating that PT or OT assessments and treatments were conducted after the resident's readmission. This oversight led to the resident experiencing a decline in physical functioning, increased dependency on staff for transfers, and a depressed mood. Observations and interviews revealed that the resident had not received any therapy services since May 2023, despite having physician orders for PT and OT from October 2023. The resident expressed feelings of frustration and a sense of being neglected by the facility staff. Staff members confirmed that the resident had become more dependent on assistance for transfers and ADLs, requiring a Hoyer lift for all transfers. The Director of Therapy was unaware of the therapy orders, and the Interim Director of Nursing Services acknowledged that the resident should have received therapy services following the hospitalization.
Failure to Inform Residents About Binding Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents were fully informed and understood the binding arbitration agreement, which was a deficiency identified during the survey. The Administrator and the Bookkeeper were responsible for explaining the Mediation and Arbitration Clause to residents upon admission. However, the Bookkeeper admitted that while the information was included in the admission handbook, she did not explain the arbitration process to residents nor did she obtain their signatures with dates. The Administrator acknowledged that the facility lacked a clear process for providing information regarding binding arbitration agreements to residents.
Infection Control and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were in place, as evidenced by several deficiencies observed during a survey. Staff members were observed using alcohol swabs to clean community use CBG monitors, which are not effective against bloodborne pathogens. This practice was acknowledged by the Director of Nursing Services, indicating a lack of adherence to proper cleaning protocols. Additionally, a resident with a chronic pressure ulcer and a history of a drug-resistant organism was not placed under enhanced barrier precautions (EBP) until four months after admission, despite having a urostomy tube and an advanced bone infection. This delay in implementing EBP was acknowledged by the Infection Preventionist. Further deficiencies were noted in the handling of clean linens, as laundry services staff were observed delivering clean clothing without adequately covering them, potentially compromising their sanitary condition. The facility also lacked a legionella water management plan, as confirmed by the Campus Director of Facility Services and the Administrator, who both acknowledged the absence of such a program since the director took the position. These failures collectively placed residents at risk for cross-contamination and infection.
Use of Undignified Language in Resident Care
Penalty
Summary
The facility failed to ensure the use of dignified language when addressing residents and their equipment, which was observed during a survey. Specifically, signs were posted on meal tray carts on both the first and second floors of the facility, instructing staff to place 'bibs/cloth protectors and green wipes only' in an open container. This language was deemed undignified and not in line with person-centered care principles, as it reflects an institutional orientation rather than a community-focused approach. Additionally, a resident with Parkinson's disease, admitted in December 2020, was referred to as a 'feeder' by staff, indicating a lack of dignified language. A CNA was observed using this term when delivering the resident's meal tray, and another staff member confirmed that the term 'feeder' was commonly used to describe residents needing supervision at mealtimes. The facility administrator acknowledged these findings but did not provide further information.
Failure to Provide Homelike Environment and Maintenance Issues
Penalty
Summary
The facility failed to provide a homelike environment for a resident admitted with dementia, as observed during a survey. The resident's room lacked personalized items or decorations, which the resident expressed a desire for. The Activities Coordinator and Social Services Coordinator indicated that it was the responsibility of the resident's family to bring personal items, and no contact had been made with the family to facilitate this. The Interim Administrator acknowledged the expectation for resident rooms to be personalized, but this was not implemented for the resident in question. Additionally, the facility's general environment was found to be lacking in maintenance and repair, with several issues identified. These included missing handrail end caps exposing sharp edges, torn and tattered furniture, missing paint on door frames, and gouges in walls with exposed drywall. The Administrator and Director of Facility Services acknowledged these maintenance concerns, indicating a need for repairs. These deficiencies suggest a failure to maintain a safe, clean, and comfortable environment as per the facility's policy.
Failure to Provide Bed Hold Policy Upon Hospital Transfer
Penalty
Summary
The facility failed to provide a bed hold policy to residents upon transfer to the hospital, as evidenced by the cases of two residents. Resident 16, who was admitted in February 2020 with a diagnosis of diabetes, was discharged to the hospital on June 24, 2024. The clinical record for Resident 16 did not show any indication that a bed hold policy was provided. Despite being cognitively intact, as revealed by an August 11, 2024, quarterly MDS, Resident 16 stated on October 7, 2024, that they did not recall receiving a bed hold policy when transferred to the hospital. Staff 2, identified as DNS, confirmed that while the policy was usually provided by the admission director upon discharge, there was currently no admission director in place. Similarly, Resident 33, admitted in December 2021 with chronic respiratory failure with hypoxia, was transferred to the hospital multiple times without receiving a written notice of the facility's bed hold policy. The health record review showed no evidence of such a policy being provided during transfers on June 1, June 14, July 11, September 8, and October 2, 2024. Staff 3 from Medical Records confirmed that the facility did not provide written bed hold policies prior to hospital transfers. The Interim Administrator, Staff 1, acknowledged the failure to provide these policies upon transfer.
Care Plan Inaccuracies Lead to Deficiencies in Resident Care
Penalty
Summary
The facility failed to ensure care plans were revised to accurately reflect the needs of residents, leading to deficiencies in care for four residents. Resident 5, admitted with paralysis, developed a deep tissue injury on the knee due to pressure from a bedside table, but the care plan was not updated to address this issue. Resident 73, admitted with a fractured hip, had discrepancies in the care plan regarding continence status and interventions for leaving the facility, which were not accurately reflected despite the resident's ability to make decisions and direct their own care. Resident 35, who had a history of stroke and difficulty swallowing, was observed using straws despite the care plan indicating otherwise, and the care plan was not updated to reflect the resident's current ability to use straws safely. Resident 7, with multiple sclerosis and contractures, had an outdated care plan that did not reflect the discontinuation of a range of motion program after a hospital admission. These inaccuracies in care plans placed residents at risk for unmet needs.
Failure to Provide Individualized Activity Programs
Penalty
Summary
The facility failed to provide an ongoing program to support individual activity interests and preferences for four residents, placing them at risk for isolation and lack of engagement. Resident 51, admitted with dementia, was noted to have preferences for reading, listening to music, and watching specific TV channels. However, the resident expressed boredom and a lack of activities, with minimal documented participation in activities that matched her/his interests. The Activity Director acknowledged that Resident 51 was unable to self-initiate activities and had limited engagement from the activity staff. Resident 340, also with dementia, was observed to have no sensory stimulation in her/his room and was not provided with activities that matched her/his preferences, such as reading or listening to music. The resident was often found in bed with the television set to a channel she/he did not understand. The Activity Director admitted unfamiliarity with Resident 340 and confirmed a lack of documented activity involvement since admission. Resident 38, cognitively intact, expressed a desire to participate in activities but reported not being invited. The resident's care plan indicated a need for assistance to attend activities, yet there was no documentation of invitations or participation in group activities. Similarly, Resident 53, with severe cognitive impairment, had limited engagement in activities despite preferences for reading and music. The Activity Director noted that Resident 53 was not invited to group activities and had not been offered sensory activities recently.
Failure to Provide Restorative Services and Monitor Range of Motion
Penalty
Summary
The facility failed to provide appropriate restorative services and treatment for residents with limited range of motion, as evidenced by the cases of four residents. Resident 5, admitted with paralysis, was initially prescribed exercises to be performed three times a week. However, due to a pressure ulcer, the resident was unable to sit at the edge of the bed, and alternative in-bed exercises were not reassessed or implemented, leading to a cessation of therapy and the resident feeling weaker. Resident 16, diagnosed with diabetes, was supposed to receive arm exercises two to three times a week. However, documentation showed multiple instances where the resident was not available for therapy, and staff indicated that the resident was not assisted by CNA staff to attend therapy sessions. This lack of assistance resulted in the resident not receiving the necessary exercises, contributing to a feeling of weakness. Resident 50, with hemiplegia and hemiparesis, was not provided with a comprehensive assessment or ongoing monitoring for contractures, despite having a care plan that included a restorative program to prevent further contractures. Observations revealed worsening contractures, and staff confirmed that the resident's condition had not been adequately monitored or referred back to therapy. Similarly, Resident 7, with multiple sclerosis, had an RA program that was discontinued after a hospital admission and was not restarted upon return, leading to worsening contractures over time.
Medication Administration Error
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, with an observed error rate of 19.23%, involving 5 errors in 26 opportunities. This deficiency was identified through observation, interview, and record review. Resident 343, diagnosed with heart disease, was prescribed levothyroxine to be taken 30 minutes before meals. However, on the observed date, the resident was given levothyroxine along with other medications such as sucubitril, metformin, and omeprazole after finishing breakfast. Staff 32, an agency LPN, administered these medications after being informed by other staff that it was acceptable to do so, despite the physician's order to administer levothyroxine without food and its known drug interactions. Staff 2, the DNS, later acknowledged the error in medication administration.
Medication and Treatment Cart Security Lapses
Penalty
Summary
The facility failed to ensure that medications and biologicals were secured and accessible only to authorized personnel across multiple halls. On several occasions, treatment and medication carts were observed to be unlocked and unattended, posing a risk for misappropriation of medications. For instance, on 1D hall, a treatment cart was left unlocked, and a CNA walked by without securing it. Later, an LPN locked the cart but stated it was not her responsibility as it belonged to the night shift. Similarly, on 1B hall, a medication cart was found unlocked with no staff in sight, and the Social Services Director had to inform a nurse about it. Further observations revealed similar issues on 2C and 1C halls, where medication carts were left unlocked and unattended. On 2C, a treatment cart was found unlocked, and an LPN confirmed this. On another occasion, a medication cart on 2C was also unlocked, confirmed by another LPN. Additionally, on 1C, a medication cart was observed unlocked, and a CMA confirmed it. The DNS acknowledged the expectation for carts to remain locked when unattended, yet the deficiency persisted across multiple observations.
Improper Food Storage Practices Identified
Penalty
Summary
The facility failed to ensure proper food storage practices in the kitchen, as observed during a survey. During an initial tour, the Dietary Manager identified and discarded several undated and unlabeled food items in both the reach-in and walk-in refrigerators. These items included a gyro sandwich, prune juice, green salads, an opened container of chicken stock base, olives, cut tomatoes, and shredded carrots. The Dietary Manager and the Interim Administrator both acknowledged that all food items in the refrigerators should have been labeled, dated, and covered, particularly those that were opened. This oversight placed residents at risk for foodborne illness, as it did not comply with the US FDA 2022 Food Code requirements for food storage.
Failure to Obtain Consents for Psychotropic Medications
Penalty
Summary
The facility failed to obtain consents for the use of psychotropic medications for two residents, which placed them at risk for the loss of the right to decline such medications. Resident 1, admitted with severe malnutrition, was cognitively intact as per the quarterly MDS and was administered Sertraline and Trazodone starting in May 2024. However, the clinical record lacked consents for these medications. Staff 2, the Director of Nursing Services (DNS), acknowledged that social services were responsible for obtaining these consents, which were not completed. Resident 77, admitted with anemia and major depressive disorder, was prescribed Celexa for depression starting in March 2024. The health record did not document that the resident was informed of the risks and benefits of Celexa, and no consent was obtained before starting the medication. Staff 2 confirmed the absence of documentation and consent for Resident 77.
Failure to Honor Resident's Room Layout Preference
Penalty
Summary
The facility failed to honor a resident's preference for room layout, which was crucial for the resident's emotional well-being. Resident 16, who was admitted in February 2020 with a diagnosis of diabetes and PTSD, expressed a desire to have their bed closer to their spouse's bed to hold hands and receive comfort during vivid dreams. Despite being cognitively intact and having communicated this preference, the request was not addressed. Observations on October 10, 2024, confirmed the beds were not moved, and the Social Services Coordinator acknowledged hearing the request but was unaware if it had been assessed. The Director of Nursing Services was also unaware of the request but stated an assessment would be necessary to ensure safety before any changes could be made.
Failure to Ensure Advance Directives for Cognitively Intact Residents
Penalty
Summary
The facility failed to ensure that residents had an advance directive, as evidenced by the cases of two residents who were cognitively intact and did not have documented advance directives. Resident 1, admitted with severe malnutrition, was found during a care conference to lack an advance directive, and there was no documentation indicating that the facility had provided information or assistance in completing one. The resident expressed uncertainty about the existence of a previous advance directive and stated a clear preference against tube feedings, highlighting the importance of having an advance directive in place. Similarly, Resident 16, admitted with diabetes, also did not have an advance directive documented in their records. The Social Services Coordinator confirmed that advance directive information should be reviewed and documented during care conferences, but there was no evidence that this was done for Resident 16. The lack of documentation and follow-up on advance directives for these residents indicates a failure in the facility's process to ensure residents' end-of-life choices are respected and documented.
Failure to Notify Emergency Contact of Hospitalization
Penalty
Summary
The facility failed to notify a resident's emergency contact of their hospitalization, which was identified during an interview and record review. Resident 16, who was cognitively intact, was admitted to the facility in February 2020 with a diagnosis of diabetes. On June 24, 2024, Resident 16 experienced symptoms including vomiting, pallor, clamminess, and altered mental status, leading to their transport to a local hospital for evaluation and treatment. Despite the critical change in medical condition, there was no documentation indicating that Resident 16's emergency contacts were informed of the hospitalization. Resident 13, who was cognitively impaired and diagnosed with dementia, was listed as Resident 16's first emergency contact, and an acquaintance was listed as the second. Staff 28, an LPN, confirmed that Resident 13 was notified but did not comprehend the situation due to their cognitive impairment. Staff 2, the DNS, acknowledged the absence of notification in Resident 16's clinical record.
Failure to Provide Required Medicare Coverage Notifications
Penalty
Summary
The facility failed to provide necessary notifications regarding Medicare coverage and potential financial liabilities to residents, as required by regulations. Specifically, two residents did not receive the Notice of Medicare Non-Coverage (NOMNC) when their Medicare Part A benefits ended, which would have informed them of their right to appeal the decision. Additionally, two residents were not given the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN), which is intended to inform them of potential out-of-pocket expenses after their Medicare coverage ended. This oversight was confirmed by the Social Services Coordinator and acknowledged by the Interim Administrator. Resident 75, who remained in the facility after their Medicare Part A coverage ended, did not receive either the NOMNC or SNF ABN notifications. Similarly, Resident 290, who was discharged home, did not receive the NOMNC notification. Resident 49, who also remained in the facility, was not provided with the SNF ABN notification. These failures placed the residents and their representatives at risk of being unaware of their rights to appeal and potential financial liabilities.
Failure to Resolve Resident Grievances Promptly
Penalty
Summary
The facility failed to ensure a system was in place to resolve resident grievances promptly, as evidenced by the case of a resident admitted in May 2022 with osteoarthritis and lower back pain. On October 7, 2024, the resident expressed concerns about a caregiver to two staff members, an RN and an LPN, and requested a grievance form be completed. However, the Interim Administrator was unaware of these concerns and confirmed on October 9, 2024, that a grievance form had not been created. The RN confirmed that she had informed the Social Services Director to complete a grievance form, and the LPN confirmed she had relayed the resident's concerns to the RN. Despite these communications, the grievance form was not completed promptly, leading to the deficiency.
Inaccurate Resident Assessments in Communication, Dental, and Transfers
Penalty
Summary
The facility failed to accurately assess residents for communication, dental, and transfer needs, leading to potential unmet care needs. Resident 14, diagnosed with Parkinson's disease, was observed to have unclear speech and required additional time and prompting to communicate effectively. Despite these observations, the resident's MDS inaccurately indicated that they were able to make themselves understood without difficulty. Staff members confirmed the resident's communication challenges, noting the need for patience and repetition during interactions. Resident 20, with a history of falls, was inaccurately assessed in their MDS as requiring partial-to-moderate assistance for transfers. However, the resident's care plan and staff interviews revealed that they required assistance from two staff members and a hoyer lift for all transfers. Additionally, Resident 1, admitted with severe malnutrition, was observed to have no teeth, yet their MDS did not reflect any dental issues. The DNS acknowledged the inaccuracies in the assessments for all three residents.
Failure to Provide Communication Tools for Resident with Hearing Impairment
Penalty
Summary
The facility failed to provide appropriate treatment and services in the area of communication for a resident with severe cognitive impairment and hearing difficulties. The resident, admitted in July 2021 with a diagnosis of dementia, was noted in a quarterly MDS assessment to have severe cognitive impairment and highly impaired hearing. Despite a care plan that included the use of a dry erase board and alternative communication tools, these were not observed in the resident's room during multiple observations from October 7 to October 14, 2024. The resident expressed difficulty in hearing and mentioned wearing hearing aids, but was unaware of their location. Staff interactions with the resident revealed significant communication challenges. A CNA reported that communicating with the resident was difficult and often involved guessing, as no communication tools or devices were used. The Social Services Director mentioned using a whiteboard for communication but was unsure if such tools were available in the resident's room for other staff. The Interim DNS acknowledged the findings and was uncertain about the communication interventions trialed with the resident, indicating a lack of awareness regarding the accuracy of the current care plan interventions.
Failure to Assist Resident with Personal Hygiene
Penalty
Summary
The facility failed to provide necessary care and services to maintain personal hygiene for a resident with dementia, who was moderately cognitively impaired and required assistance with personal hygiene. The resident was observed over several days with significant chin hairs and expressed a desire to have them shaved. Despite the Kardex directing staff to shave the resident as necessary, and staff acknowledging the need to assist the resident, the resident remained unshaven. The Interim DNS stated that the expectation was for the resident to be shaven on scheduled days, which was not adhered to, leading to the deficiency.
Failure to Address Resident's Worsening Depression
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident diagnosed with depression and adjustment disorder, leading to ongoing signs of depressive behavior. The resident, admitted in September 2022, showed a progressive increase in depressive symptoms as indicated by the Patient Health Questionnaire-9 (PHQ-9) scores from March to September 2024. Despite these worsening scores, the resident's care plan did not reflect any new or additional interventions to address the deteriorating mood state. The care plan remained unchanged from June to September 2024, failing to incorporate strategies to manage the resident's depressive symptoms effectively. Observations and interviews revealed that the resident spent most of the time in bed, feeling neglected by the staff and not participating in activities. The Social Services Director admitted to a lack of a proper system for reporting changes in PHQ-9 scores or new mood symptoms to the resident care manager. Consequently, the Interim Director of Nursing Services, who was also the resident care manager, was unaware of the resident's worsening condition. This lack of communication and failure to update the care plan placed the resident at risk of not maintaining their highest practicable physical, mental, and psychosocial well-being.
Failure to Provide Routine Medications for Residents
Penalty
Summary
The facility failed to provide routine medications for two residents, leading to deficiencies in pharmaceutical services. Resident 33, who was admitted with chronic respiratory failure and hypoxia, did not receive prescribed medications including Vitamin B12, folic acid, and Invokana on multiple occasions in September 2024. Staff members, including an RN and a CMA, acknowledged the unavailability of these medications but failed to notify the charge nurse or contact the pharmacy and provider for further instructions. The Interim DNS confirmed the oversight and acknowledged that neither the pharmacy nor the provider was contacted regarding the missed doses. Similarly, Resident 49, admitted with hyperlipidemia and kidney failure, did not receive pravastatin for cholesterol management on several dates in October 2024. Additionally, Resident 49 was not provided with oxycodone for pain management on two occasions, despite experiencing moderate pain and requesting the medication. Staff 13, an LPN, was unable to locate the medications in the cart and did not communicate the issue to the physician or take action to obtain the medications. The Interim DNS confirmed the lack of communication and action regarding the unavailability of Resident 49's medications. These incidents highlight a failure in the facility's medication management system, where prescribed medications were not available, and appropriate steps were not taken to address the issue. The lack of communication and follow-up with the pharmacy and providers resulted in residents not receiving necessary medications, which could potentially impact their health and well-being.
Failure to Monitor Antidepressant Side Effects
Penalty
Summary
The facility failed to monitor a resident for side effects of antidepressants, which was identified during an interview and record review. The resident, admitted in May 2024 with severe malnutrition, was prescribed trazodone and sertraline daily starting from the same month. A care plan initiated at the end of May 2024 noted potential side effects of these medications, including drowsiness, suicidal thoughts, confusion, and increased falls. However, the clinical record lacked documentation of staff monitoring for these side effects. On October 10, 2024, the Director of Nursing Services (DNS) confirmed that staff were supposed to document side effect monitoring on the Medication Administration Records (MARs) but acknowledged that this was not done for the resident.
Failure to Schedule Follow-Up Dental Exam
Penalty
Summary
The facility failed to ensure a follow-up dental exam was scheduled for a resident who had all their teeth extracted. The resident, admitted in February 2020 with a diagnosis of diabetes, was cognitively intact as per an August 2024 quarterly MDS. A progress note from July 2024 indicated that all of the resident's teeth were extracted. However, by October 2024, the resident was not on the list for an upcoming dental appointment, despite expressing a desire for dentures and noting that no follow-up appointments had been made. The Social Services Director acknowledged that the resident was not on the current list to be seen by a dentist, and the dentist confirmed that gums typically heal in about eight weeks, after which the denture process could begin.
Failure to Prevent Accident Hazards and Ensure Adequate Supervision
Penalty
Summary
The facility failed to ensure residents were free from accident hazards, affecting three residents. Resident 6, who was cognitively intact and required a two-person transfer, was observed being transferred by a single staff member using a mechanical device, which caused the resident to feel fearful and almost fall. Staff acknowledged that Resident 6 required two staff for transfers, indicating a failure to adhere to the care plan. Resident 60, also cognitively intact, had wound care medications left unsecured in their room, posing an accident hazard. The medications, including Triad Hydrophilic Wound Dressing and iodine, were observed on the countertop, contrary to the facility's protocol of securing such items. Additionally, Resident 50, who was severely cognitively impaired and at moderate risk for falls, was found in a bed that was not in the low position, and without fall mats as required by their care plan. This oversight led to the resident's legs hanging off the bed and getting caught in the sheets, further highlighting the facility's failure to provide adequate supervision and accident prevention measures.
Incomplete Discharge Summary Leads to Resident's Hospital Re-admission
Penalty
Summary
The facility failed to complete a discharge summary with the necessary information for wound care and potential wound infection for a resident, leading to the resident's condition worsening at home and resulting in re-admission to a hospital. The resident, who had been admitted with a hip fracture, heart failure, and a history of falling, required frequent skin inspections and was at risk for developing pressure injuries. Despite these needs, the discharge summary did not include instructions for wound care or follow-up for a possible infection, and the resident was discharged without having the surgical staples removed or a follow-up appointment with the orthopedic surgeon. The resident's weekly skin evaluation noted several issues, including incisions with intact staples, drainage, redness, and swelling, as well as new skin issues such as a rash and increased redness and warmth in the right lower extremities. Staff identified these concerns and noted the need for close monitoring and follow-up with the surgeon, but these actions were not completed before discharge. The discharge instructions were incomplete, lacking essential information such as contact details for healthcare providers, home health needs, medication education, and infection information. Upon discharge, the resident's family observed a decline in the resident's mental and physical condition, leading to a hospital visit where a post-operative wound infection was diagnosed. The hospital found that the surgical staples had not been removed, and the wounds showed signs of infection and dehiscence. The facility's failure to provide adequate discharge instructions and follow-up care contributed to the resident's deterioration and subsequent hospital re-admission.
Improper Oxygen Administration for Resident
Penalty
Summary
The facility failed to adhere to physician orders regarding the administration of oxygen for a resident, leading to improper oxygen administration. The resident, who was admitted with diagnoses including diabetes and kidney disease, had a physician's order to receive oxygen via nasal cannula at 3 liters per minute (lpm) following a hospital visit. However, records indicate that on multiple occasions, the resident received incorrect oxygen flow rates: 2/lpm on one occasion and 4/lpm on several others. This inconsistency in following the prescribed oxygen flow rate placed the resident at risk for improper oxygen administration. Additionally, the facility incorrectly used an oxygen face mask instead of a nasal cannula for the resident, despite the physician's order specifying the use of a nasal cannula. The resident experienced difficulty breathing, with oxygen saturation levels dropping to 85% while on 4/lpm via face mask, which was above the ordered flow rate. The resident refused to wear the face mask due to discomfort and was eventually transferred to the hospital. Staff members verified the incorrect use of the face mask and the failure to follow the prescribed oxygen administration orders.
Inadequate Oxygen Administration Training
Penalty
Summary
The facility failed to ensure that licensed nursing staff had the necessary competencies and skill sets for proper oxygen administration, which affected one of the three sampled residents. The deficiency was identified when a resident, admitted with diagnoses of diabetes and kidney disease, experienced difficulty breathing. The resident's oxygen saturation levels were below normal, and the oxygen was incorrectly administered at 3 liters per minute (lpm) via a face mask, which is below the recommended minimum of 6 lpm to prevent rebreathing of exhaled carbon dioxide. Staff interviews revealed that the RN and LPN involved were unaware of the correct oxygen flow rate required for a face mask and had not received adequate training on oxygen administration. The resident's condition worsened, leading to a request for hospital transfer. The facility's staff development acknowledged the need for more training on oxygen administration, indicating a gap in staff education and competency in this area.
Failure to Maintain Clean Wheelchairs
Penalty
Summary
The facility failed to maintain clean and sanitary conditions for wheelchairs, as evidenced by the condition of a resident's wheelchair. The resident, who was admitted in November 2019 with multiple sclerosis and paraplegia, was observed on multiple occasions with a wheelchair that had crumbs and brown smudge marks on the bottom cushion and armrest. These observations were made on three separate dates in July 2024, indicating a lack of regular cleaning and maintenance of the wheelchair. Despite the facility's documentation stating that the wheelchair was cleaned monthly and as needed, the resident's wheelchair remained dirty. The resident council notes from April and June 2024 also highlighted concerns from residents about the cleanliness of their wheelchairs and requested a cleaning schedule. Staff members, including an Agency CNA and LPNs, verified the unclean condition of the wheelchair, with one LPN admitting to documenting the cleaning without actually performing it.
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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