Tigard Rehabilitation And Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Tigard, Oregon.
- Location
- 14145 Sw 105th Avenue, Tigard, Oregon 97224
- CMS Provider Number
- 385272
- Inspections on file
- 23
- Latest survey
- November 17, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Tigard Rehabilitation And Care during CMS and state inspections, most recent first.
A resident admitted with heart failure and diabetes was found to have a blister on the left knee during the admission assessment. Although the care plan noted impaired skin integrity, staff did not implement monitoring or complete further assessments of the wound, and the required documentation and alert charting were not initiated.
A resident with osteomyelitis developed new pressure ulcers that were not comprehensively assessed or treated in a timely manner. After a CNA reported an open sore, an LPN cleaned and covered the wound but did not measure it, obtain provider orders, or document treatment. Wound care orders and comprehensive assessment were delayed by two days, and wound care was not provided until the following day, contrary to facility protocol and national guidelines.
The facility did not maintain accurate records or account for all controlled drugs, resulting in missing narcotic medication for two residents. Staff interviews confirmed knowledge of the missing medication, but the facility was unable to determine its whereabouts, indicating a failure to follow required procedures for reconciling and documenting controlled substances.
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.
The facility failed to monitor refrigerator temperatures and label food items properly, risking foodborne illnesses. Observations showed that temperatures were recorded only once, and food items lacked dates or names. Staff interviews revealed a lack of awareness and adherence to the facility's policy, leading to the deficiency.
A resident with limited English proficiency was not provided with important documents in their preferred language, Spanish, despite needing an interpreter. This included critical documents like POLST and Medicare notices. Staff confirmed the resident's language needs, but the facility failed to ensure communication was in a language the resident could understand.
The facility did not deliver resident mail on Saturdays, contrary to its policy requiring mail delivery within 24 hours, including weekends. Residents reported this issue during a council meeting, and the Activities Director confirmed that mail was only distributed Monday through Friday. The Administrator acknowledged that mail should be delivered on the same day it arrives.
A facility failed to create a comprehensive care plan for a resident with diabetes and chronic suicidal ideation. Despite assessments and progress notes indicating mood issues, depression, and behavioral problems, these concerns were not included in the care plan. Staff interviews revealed a lack of awareness and monitoring of the resident's mood, with some staff acknowledging the resident's expressions of wanting to die. The DNS expected these issues to be addressed, but the Social Services Director did not perceive them as significant enough for the care plan.
A resident with a diabetic foot ulcer and venous ulcers did not receive timely wound care upon admission. Despite being aware of the wounds, the facility failed to obtain treatment orders for over a month, leading to a delay in care. This oversight was confirmed by staff, highlighting a significant lapse in the facility's wound management protocol.
A resident with malnutrition and type 1 diabetes experienced significant weight loss, dropping from an average of 205.5 pounds to 174.6 pounds. Despite this, the facility delayed a reweigh and did not implement new nutritional interventions or review the resident in the Nutritional at Risk group in a timely manner. The RD acknowledged these delays, which placed the resident at risk for continued weight loss.
The facility did not conduct annual performance reviews for four CNAs, as confirmed by the DNS and Staffing Coordinator. This oversight placed residents at risk of receiving care from potentially incompetent staff.
A facility failed to ensure resident dignity and respect when a verbal altercation between two residents resulted in one resident spitting in the other's face. The incident, witnessed by staff, occurred over a borrowed wheelchair. Despite one resident's denial, staff confirmed the spitting incident, and both residents were placed on safety monitoring.
A resident with a history of inappropriate sexual behavior was found with their hand inside another resident's brief while the latter was asleep. Both residents had severe cognitive impairments, and the incident was witnessed by a staff member. The facility's records indicated prior knowledge of the offending resident's behavior, yet the incident occurred, placing residents at risk for repeat abuse.
A facility failed to provide wound care for a diabetic resident as per physician orders. The resident's orders required specific wound care procedures, including cleaning, applying AD ointment, and securing with bordered foam, to be performed three times weekly. However, no wound care was documented for over two weeks, as confirmed by the DNS.
Failure to Monitor Non-Pressure Skin Wound
Penalty
Summary
The facility failed to monitor a non-pressure skin wound for one resident who was admitted with diagnoses including heart failure and diabetes. Upon admission, a clinical progress note documented redness and a small healing blister on the resident's front left knee. The care plan identified impaired skin integrity due to the blister and immobility. However, a review of the medical record and treatment administration record (TAR) showed no assessment or monitoring of the wound during the resident's stay. Staff confirmed that although the blister was identified during the admission assessment, monitoring was not implemented, and no further assessments were completed. Facility leadership stated that the expected protocol for skin impairments was not followed, as the blister was not documented for ongoing monitoring or alert charting.
Failure to Timely Assess and Treat Newly Identified Pressure Ulcers
Penalty
Summary
The facility failed to ensure that newly identified pressure ulcer wounds were comprehensively assessed and that wound care orders were obtained and implemented for a resident with a diagnosis of osteomyelitis of the vertebrae. After admission, a CNA notified an LPN of an open sore on the upper part of the resident's buttock. The LPN observed, cleaned, and covered the wound, and initiated a Skin Integrity Report, but did not measure the wound, obtain provider orders, document wound treatment, or initiate any wound care protocol on the Treatment Administration Record (TAR) at that time. There was no evidence in the health record of a comprehensive wound assessment, including measurement, location, stage, or other characteristics, between the initial identification of the wound and two days later. Wound care orders were not obtained until two days after the wound was first identified, and wound care was not provided until the following day. The Director of Nursing Services confirmed that the wound was not comprehensively assessed and measured until two days after it was first identified, and that there was no evidence of wound care being provided during that period. This lapse in timely assessment and intervention did not follow the facility's protocol or national guidelines for pressure ulcer care.
Failure to Maintain Accurate Narcotic Drug Records
Penalty
Summary
The facility failed to ensure that narcotic drug records were properly maintained and that an accurate account of all controlled drugs was kept for one of three narcotic books reviewed. According to the facility's policy, nursing staff are required to count controlled medication inventory at the end of each shift, with both the incoming and outgoing nurses reconciling and documenting the count, and reporting any discrepancies to the Director of Nursing Services (DNS). However, a review of records revealed that narcotic medication for two residents was missing and unaccounted for, and the facility was unable to determine what happened to the missing medication. Staff interviews confirmed awareness of the missing narcotic medication but did not provide information on its whereabouts. The deficiency was identified when a former DNS discovered two missing narcotic cards during a review of the facility's narcotic books. Subsequent investigation and staff interviews indicated that the required procedures for reconciling and documenting controlled substances were not followed, resulting in the loss of narcotic medication. The lack of proper record-keeping and reconciliation placed residents at risk for drug diversion.
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 Monitor and Label Food Storage
Penalty
Summary
The facility failed to ensure proper monitoring and labeling of food storage in two refrigerators, which placed residents at risk for potential foodborne illnesses. Observations revealed that the refrigerator used to store resident food items in the dining room had a temperature log, but temperatures were only recorded once on 1/10/25. Additionally, food items in the refrigerator were found without dates or names. Staff interviews indicated a lack of awareness and adherence to the facility's policy, which required daily temperature checks and proper labeling of food. The Dietary Manager was unaware of the monitoring process for the resident foods refrigerator, and a CNA was unsure of the labeling policy. This lack of compliance with the facility's policy led to the deficiency.
Failure to Provide Language-Appropriate Communication
Penalty
Summary
The facility failed to ensure that a resident, who primarily spoke Spanish and required an interpreter, received communication in a language they could understand. The resident was admitted with a diagnosis of diabetes and had a care plan indicating a preference for Spanish. Despite this, several important documents, including Portable Orders for Life-Sustaining Treatment (POLST), Notices of Medicare Non-Coverage, and SNF Discharge Instructions, were provided to the resident in English only. Interviews with staff confirmed the resident's limited English proficiency and the need for translation services, yet the facility did not provide documents in Spanish, leading to a lack of involvement in the resident's care.
Failure to Deliver Resident Mail on Saturdays
Penalty
Summary
The facility failed to ensure that resident mail was delivered on Saturdays, as required by their Mail and Electronic Communication policy revised in 2017. This policy mandates that mail and packages be delivered to residents within twenty-four hours of delivery to the premises, including Saturdays. During a resident council meeting, residents reported that their mail was not delivered on Saturdays. Staff 20, the Activities Director, confirmed that mail was only delivered to residents from Monday through Friday, and any mail received on Saturdays was not distributed until the following Monday. Staff 1, the Administrator, acknowledged that resident mail should be delivered on the same day it arrives at the facility.
Failure to Develop Comprehensive Care Plan for Resident with Mood Issues
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident admitted with diagnoses including diabetes and chronic suicidal ideation. Despite multiple assessments and progress notes indicating the resident's mood issues, including depression, suicidal ideation, and behavioral problems such as yelling and combativeness, the facility did not include these concerns in the resident's care plan. Interviews with staff revealed a lack of awareness and monitoring of the resident's mood and behaviors, with some staff members acknowledging the resident's expressions of wanting to die and feelings of helplessness. The Director of Nursing Services expected mood and behavior issues to be addressed in the care plan, yet the Social Services Director did not perceive the resident's mood issues as significant enough to warrant inclusion in the care plan. This oversight placed the resident at risk for unmet needs, as there was no structured plan to monitor or address the resident's mental health and behavioral issues, despite the resident's history and ongoing expressions of distress.
Failure to Provide Timely Wound Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with multiple wounds, including a diabetic foot ulcer and venous ulcers, upon admission. The resident was admitted with a known right foot ulcer, but daily skilled evaluations from early October to early November did not include assessments of this ulcer. Additionally, physician progress notes during this period did not address the ulcer. A skin check assessment in late November revealed additional venous ulcers on the resident's left leg, which were reportedly present since admission, yet no treatment orders were in place. It was not until late November that the facility requested and obtained orders for wound care for the resident's right foot ulcer and newly identified wounds on the left lower extremity and buttocks. Staff confirmed that the facility was aware of the wounds upon admission but failed to secure treatment orders until over a month later. This oversight placed the resident at risk for worsening wounds due to the lack of timely and appropriate care.
Failure to Timely Address Resident's Weight Loss
Penalty
Summary
The facility failed to ensure that a resident was properly assessed after significant weight loss was identified. Resident 34, who was admitted with diagnoses including malnutrition and type 1 diabetes, experienced a notable weight loss from an average of 205.5 pounds to 174.6 pounds over a period of time. Despite the identification of this weight loss on 9/23/24, a reweigh was not conducted until 10/7/24, two weeks after the initial request. During this period, no new nutritional interventions were implemented, and the resident was not reviewed by the Nutritional at Risk (NAR) group until 10/22/24, which was three days after readmission from a hospital stay related to diabetes. Staff 13, the Registered Dietitian (RD), acknowledged that the reweigh recommendation was not completed in a timely manner and that the resident was not reviewed in the NAR group within the expected timeframe. This delay in assessment and intervention placed the resident at risk for continued weight loss. Observations made in January 2025 indicated that the resident was capable of feeding themselves and consumed 100% of their meals, suggesting that earlier intervention might have been beneficial.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received annual performance reviews, as evidenced by the lack of performance reviews for four randomly selected CNA staff members. On January 14, 2025, the Director of Nursing Services (DNS) was unable to provide the requested performance reviews for the identified CNAs. The following day, the Staffing Coordinator acknowledged that no performance reviews had been completed for these staff members. This deficiency placed residents at risk for receiving care from potentially incompetent staff.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by an incident involving two residents. Resident 2, who was admitted to the facility with hyperlipidemia, was involved in a verbal altercation with Resident 1, who had chronic systolic heart failure. The altercation occurred in the facility parking lot when Resident 2 requested the return of a spare wheelchair borrowed by Resident 1. During the altercation, Resident 1 was observed spitting in the face of Resident 2, which was confirmed by multiple staff witnesses. Staff 3 and Staff 4, who witnessed the incident, intervened to separate the residents and ensure their safety. Resident 2 expressed feeling offended and disrespected by the incident but declined a physical assessment, stating no injuries were sustained. Despite Resident 1's denial of spitting, both staff members confirmed the act occurred. The incident was documented in a Facility Reported Incident, and both residents were placed on safety monitoring to prevent further occurrences.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect residents from sexual abuse, as evidenced by an incident involving two residents with severe cognitive impairments. Resident 1, who has a history of trauma related to domestic violence, was found to have been sexually abused by Resident 2, who has a history of inappropriate sexual behavior. On the evening of April 29, 2024, Resident 2 was discovered with their hand inside Resident 1's brief while Resident 1 was asleep. This incident was witnessed by a staff member, who observed Resident 2 exposing Resident 1's right hip and buttocks. The facility's records indicated that Resident 2 had been previously identified with inappropriate sexual behavior, yet was able to access Resident 1's room and engage in the abusive act. The incident was reported to the police, and it was acknowledged by the facility's administrator and director of nursing services. The failure to prevent this incident placed residents at risk for potential repeat sexual abuse incidents.
Failure to Provide Diabetic Wound Care
Penalty
Summary
The facility failed to provide appropriate wound care treatment according to physician orders for a resident with a diabetic wound. The resident, admitted in May 2023 with a diagnosis of diabetes, had specific physician orders dated October 10, 2023, for the care of a diabetic wound on the right toe. The orders required the wound to be cleaned with wound cleanser, a thin layer of AD ointment to be applied to the wound and periwound, and the wound to be secured with bordered foam. The dressing was to be changed three times per week and as needed. However, a review of the resident's October 2023 Treatment Administration Record (TAR) revealed that no wound care was documented as being performed from October 11, 2023, through October 27, 2023. This lapse in care was confirmed by Staff 2, the Director of Nursing Services (DNS), on April 10, 2024, indicating a failure to adhere to the prescribed wound care regimen.
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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