Village Health Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Gresham, Oregon.
- Location
- 3955 Se 182nd Avenue, Gresham, Oregon 97030
- CMS Provider Number
- 385068
- Inspections on file
- 19
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Village Health Care during CMS and state inspections, most recent first.
A resident with spinal stenosis and chronic kidney disease, who required partial to moderate assistance with bathing and transfers, was being transported back to their room in a rolling shower chair by a NA student. At the doorway, the chair became stuck on a transition strip; despite the resident stating they were usually taken into the room backwards because of this strip, the NA student attempted to free the chair by lifting on the backrest. The backrest detached, causing the resident to fall backwards to the floor. The resident reported fear and some back pain after the fall, and staff assessment found no major injury. The DNS later confirmed the fall was due to incorrect and unsafe techniques used by the NA student.
A resident with significant mobility and skin integrity risks developed multiple new pressure ulcers over several months. Despite existing care plan interventions, staff did not document reassessment or implement additional interventions after new wounds appeared. Nursing staff acknowledged that further measures should have been taken, but these were not documented or followed up.
A resident with heart failure and COPD did not receive prescribed lasix for four days due to a charting error and system glitch after a medication order change. The lapse led to worsening symptoms, including swelling and respiratory distress, resulting in hospitalization for acute hypoxemic respiratory failure. The facility confirmed the medication error and its clinical consequences.
The facility failed to follow proper infection control practices during CBG monitoring for a resident with diabetes and renal disease, as staff did not use barriers or perform hand hygiene between glove changes. Additionally, Enhanced Barrier Precautions were not implemented for residents with MDROs, and droplet precautions were not followed for a resident with influenza, as staff were unaware of the necessary precautions and PPE was not readily available.
The facility did not ensure residents were informed of their rights both orally and in writing on an ongoing basis. Resident Council members were unaware of their rights and unsure if they were posted or accessible. Meeting minutes from several dates showed no evidence of rights being reviewed. The administrator acknowledged the issue, believing rights were reviewed through the Resident Council.
The facility did not have a system to deliver mail to residents on Saturdays. During a Resident Council interview, residents reported not receiving mail on Saturdays. A review of activity participation charts from November 2024 to January 2025 confirmed this issue, and the administrator acknowledged the lack of a Saturday mail delivery system.
The facility failed to comprehensively assess three residents for medications, ROM, and behaviors, resulting in unassessed needs and a lack of person-centered care plans. One resident with major depression and schizophrenia lacked detailed analysis in their CAAs for psychotropics and other areas. Another resident with a stroke and hemiplegia had incomplete analysis in their Functional Abilities CAA. A third resident showed a decline in mood, but their health record lacked assessment of contributing factors, and no CAA was completed.
The facility failed to provide person-centered activity programs for four residents, leading to a risk of decline in psychosocial well-being. Residents with various diagnoses, including stroke, schizophrenia, dementia, and congestive heart failure, were not engaged in activities despite having interests in music, reading, and social interactions. Staff confirmed the lack of activity care plans and awareness of residents' preferences, resulting in residents being left alone and unengaged.
The facility failed to provide a designated licensed nurse (LN) as a charge nurse for 36 out of 81 shifts over a period of nearly a month. This lack of LN coverage was confirmed by the Staffing Coordinator and the Administrator, who was unaware of the staffing situation. The absence of LN coverage placed residents at risk for unmet needs, as the facility did not ensure the necessary nursing services for resident safety and well-being.
The facility did not ensure RN coverage for at least eight consecutive hours per day on nine occasions, as required. This lack of coverage was acknowledged by the Staffing Coordinator and Administrator, placing residents at risk for inadequate RN assessments and care.
A resident with upper extremity impairments experienced difficulty feeding themselves due to the use of plastic and Styrofoam dishware, which was not sturdy enough, leading to spills. This practice, ongoing for at least two months, was due to regular dishware being unavailable. Staff interviews confirmed the issue, and the new Dietary Manager acknowledged the non-dignified nature of the dishware after a facility walk-through.
A facility failed to inform a resident with generalized anxiety disorder about the risks and benefits of psychotropic medications and did not obtain consent for their use. The resident was receiving Citralopram Hydrobromide and Aprazolam as prescribed, but there was no documentation of informed consent. The DNS confirmed that nursing staff were expected to review medication risks and benefits with residents, which was not done in this instance.
A resident, admitted with a heart attack and fractured leg, was not involved in their care planning despite being cognitively independent and their own responsible party. The resident was unaware of their care plan contents, and staff confirmed the absence of documentation or a care conference. The DNS expected care conferences to occur within 72 hours of admission.
The facility failed to assess the appropriateness of self-administration of medication for two residents, placing them at risk for unsafe medication administration. One resident with a stroke had a nasal spray within reach without an assessment, and another with COPD had an albuterol inhaler without being assessed for self-administration safety. Staff confirmed that neither resident had been evaluated for their ability to self-administer these medications.
A resident with Aphasia had their call light out of reach, contrary to their care plan. Observations showed the call light wrapped around the bed frame, and residents reported similar issues during a council meeting. A CNA and the DNS confirmed the call light was inaccessible, highlighting a failure to follow the care plan.
The facility failed to provide a SNF ABN to a resident who was admitted with Medicare A benefits. The resident's Medicare Part A benefits ended, and they were financially responsible for their care without being informed of the daily out-of-pocket costs. The DNS reported that the facility was not providing SNF ABN notifications to residents or their representatives.
The facility failed to ensure accurate assessments for two residents, leading to potential unmet care needs. A resident with diabetes had inconsistent MDS assessments regarding cognitive status and opioid medication use. Another resident with anxiety disorder had discrepancies in MDS assessments about the use of corrective lenses, despite being observed wearing glasses. Staff confirmed the inaccuracies.
A facility failed to conduct a new and accurate Level I PASARR for a resident with Bi-Polar Disorder, Major Depressive Disorder, and anxiety, who exhibited behaviors such as hallucinations and self-isolation. Despite these indicators, no corrected Level I PASARR or referral for Level II PASARR was made, as acknowledged by staff. This oversight risked delaying care and services for the resident's mental health needs.
The facility failed to create comprehensive baseline care plans within 48 hours for two residents upon admission, leading to unmet care needs. One resident with complex medical conditions had a care plan addressing only nutrition, while another resident with cognitive impairment had no care plan, resulting in a fall and hip fracture. Staff acknowledged these oversights, indicating a lapse in immediate care planning.
A resident with anxiety disorder experienced impaired vision due to a scratched lens on their glasses, which were damaged during a fall at the facility. Despite the resident's report of hazy vision, the facility did not provide the necessary assistance to repair or replace the glasses, as confirmed by staff.
The facility failed to provide regular restorative nursing services for two residents with impaired mobility due to staffing issues. One resident, with hemiparesis, reported increased difficulty in walking and pain due to irregular services. Another resident expressed a desire to be more active, but staffing shortages led to inconsistent service delivery. Staff confirmed the lack of a tracking system for restorative services.
A resident with anxiety, cancer, and an abscess of the lower limb did not receive timely pain medication due to the facility's failure to update pain medication instructions. The resident's Comprehensive Care Plan did not address specific pain needs, leading to inconsistent interpretation of PRN orders by nursing staff. Despite the provider's clarification on dosing intervals, the resident's MAR and Care Plan were not updated, resulting in the resident not receiving timely oxycodone doses.
A facility failed to ensure proper dialysis services and communication for a resident with end-stage renal disease. The required communication reports were not completed, and necessary assessments were not conducted upon the resident's return from dialysis, placing the resident at risk for complications.
A facility failed to act on pharmacy recommendations to limit the use of PRN antipsychotic medication for a resident with major depression, schizophrenia, and anxiety disorder. The resident's MARs indicated continuous use of Seroquel beyond the recommended 14-day limit. The Consultant Pharmacist had sent reviews and notes to the prescriber, but there was no evidence that the December pharmacy review was completed or acted upon.
A facility failed to limit the PRN use of Seroquel, an antipsychotic medication, to 14 days for a resident with major depression, schizophrenia, and anxiety disorder. The medication was administered 15 times in December and eight times in January before the order was adjusted to a 14-day duration. This was confirmed by a Corporate Nurse Consultant, highlighting a lapse in adhering to the 14-day limitation for PRN antipsychotic use.
The facility inaccurately documented physician orders for two residents, leading to discrepancies in care. One resident received the wrong diet texture, while another received conflicting weight-bearing instructions. Staff confirmed the errors in transcription and documentation.
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their specific needs. One resident's care plan did not address the use of PRN diazepam for auras or seizure activity, nor potential cognitive changes. Another resident's care plan lacked specific interventions for behaviors related to mental illness. Staff acknowledged the absence of resident-centered interventions.
A facility failed to provide proper care for a resident with skin conditions and did not ensure person-centered medication management for another resident. One resident had significant bruising and an abrasion without documented assessments or treatments. Another resident experienced issues with medication management, expressing frustration over the administration of sedating medications, which was not adequately addressed in their care plan.
The facility failed to post accurate staffing information, with 17 days of incomplete or inaccurate Direct Care Staff Daily Reports. Issues included missing daily census data, absent signatures, and incorrect staff numbers. The Administrator acknowledged these inaccuracies.
Fall from Rolling Shower Chair Due to Improper Handling at Doorway Transition
Penalty
Summary
The facility failed to ensure safe use of bathing equipment and adequate supervision during transport in a rolling shower chair, resulting in a fall for one resident. The resident, admitted with diagnoses including spinal stenosis and chronic kidney disease, had a care plan indicating a need for partial to moderate assistance with bathing and bathing transfers. On the date of the incident, a NA student assisted the resident back to their room in a rolling shower chair. As they attempted to cross the transition strip at the doorway, the shower chair became stuck. The resident informed the NA student that they were usually assisted into the room backwards because of the transition strip. The NA student attempted to dislodge the stuck wheel by lifting up on the backrest of the rolling shower chair, causing the backrest to detach and the resident to fall backwards onto the floor. The resident recalled falling out of the shower chair and reported feeling afraid immediately after the incident. Staff, including an RN and the shower aide, assessed the resident after the fall and noted no major injury, with the resident able to stand and walk to bed, though minimal increase in back pain was reported. The DNS confirmed that the fall occurred due to incorrect and unsafe techniques used by the NA student when handling the rolling shower chair at the doorway transition strip.
Failure to Re-Evaluate and Update Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to re-evaluate and update preventative interventions for a resident who developed multiple new pressure ulcers. The resident, who had a history of stroke with left-sided deficits, impaired mobility, incontinence, and other comorbidities, was identified as being at risk for skin integrity issues. Despite the care plan outlining several interventions such as frequent repositioning, offloading, and moisture management, the resident developed a superficial open area on the left buttock, moisture-associated skin damage to the coccyx, and an unstageable pressure wound to the heel over a period of several months. Record review and staff interviews revealed that there was no documented evidence of reassessment or modification of the care plan interventions after the development of new pressure ulcers. Nursing staff acknowledged that additional interventions should have been implemented but were not. Recommendations for interventions, such as a pressure-reducing air mattress, were made verbally but not documented or followed up. The lack of timely re-evaluation and implementation of new interventions contributed to the resident developing additional pressure ulcers.
Significant Medication Error Resulting in Hospitalization
Penalty
Summary
A resident with chronic obstructive pulmonary disease and congestive heart failure was admitted to the facility and had physician orders for lasix to manage fluid buildup. The resident's lasix regimen was changed from once daily to twice daily for five days due to increased swelling, requiring the original order to be stopped. Due to a charting error on the medication administration record (MAR) and a reported glitch in the computer system, the resident did not receive lasix for four consecutive days. The nurse responsible for the medication change was unable to place the medication on hold in the system, discontinued the original order, and communicated her concerns to the provider and care manager, but assumed the issue would be addressed by others during clinical rounds. As a result of not receiving lasix, the resident developed significant clinical symptoms, including increased swelling, shortness of breath, and lowered oxygen levels. The resident was subsequently hospitalized for acute hypoxemic respiratory failure, with hospital records indicating volume overload and elevated BNP levels attributed to medication non-adherence. The facility confirmed the medication error and its impact through internal investigation and communication with the State Survey Agency.
Infection Control Deficiencies in Hand Hygiene and Precautionary Measures
Penalty
Summary
The facility failed to ensure proper hand hygiene and infection control practices during capillary blood glucose (CBG) monitoring for a resident with diabetes and end-stage renal disease. Staff 11, a registered nurse, did not use a barrier on the resident's dirty bedside table when placing CBG supplies, nor did they perform hand hygiene between glove changes. The glucometer was placed on the medication cart without a barrier, and the cart was not disinfected. These actions were contrary to the facility's infection control policies and placed the resident at risk of contamination. The facility also failed to implement Enhanced Barrier Precautions (EBP) for residents with multidrug-resistant organisms (MDROs), wounds, or indwelling medical devices. Observations revealed that there was no signage or personal protective equipment (PPE) supplies outside the rooms of residents requiring EBPs. Staff members were unaware of the need for gown and glove use during high-contact care activities, and the facility did not have the necessary PPE kits available, which was acknowledged by the Director of Nursing Services and the Regional President. Additionally, the facility did not follow droplet precautions for a resident diagnosed with influenza. Although a PPE cart was present outside the resident's room, there was no sign indicating the type of precautions to be followed. Staff members were unsure of the required precautions, and housekeeping staff did not wear appropriate eye protection while in the resident's room. The Director of Nursing Services confirmed that droplet precautions should have been in place until the resident was reassessed and physician orders updated.
Failure to Inform Residents of Their Rights
Penalty
Summary
The facility failed to ensure that residents were informed of their rights both orally and in writing on an ongoing basis. This deficiency was identified during an interview with Resident Council members on January 30, 2025, who stated they were not informed of resident rights regularly and were unsure if any rights were posted in the facility or where to obtain them. A review of Resident Council Meeting minutes from November 12, 2024, December 10, 2024, and January 17, 2025, showed no evidence that resident rights were provided to or reviewed with residents during these meetings or by any other method. The facility's administrator, Staff 1, acknowledged the issue, stating he believed resident rights were reviewed through the Resident Council and was unaware of any other method used to communicate these rights.
Lack of Saturday Mail Delivery System
Penalty
Summary
The facility failed to have a system in place to deliver mail to residents on Saturdays, as determined through interviews and record reviews. During a Resident Council group interview, residents reported that their mail was not delivered on Saturdays. A review of resident activity participation charts from November 2024 through January 2025 showed no evidence of mail delivery on Saturdays. The facility's administrator confirmed the absence of a system for Saturday mail delivery.
Deficiencies in Comprehensive Resident Assessments
Penalty
Summary
The facility failed to comprehensively assess three residents for medications, range of motion (ROM), and behaviors, leading to unassessed needs and a lack of person-centered care plans. Resident 15, admitted in 2019 with diagnoses including major depression and schizophrenia, had an annual MDS assessment indicating mild cognitive impairment and was prescribed psychotropic medications. However, the Care Area Assessments (CAAs) for psychotropics, falls, nutrition, and functional ability lacked a detailed analysis of the resident's conditions, behaviors, and risk factors associated with the use of psychotropic medications. Staff confirmed that the CAAs did not include an analysis of the triggered concerns. Resident 33, admitted in 2021 with a stroke and hemiplegia, was identified as cognitively intact but had a ROM impairment and used mobility aids. The Functional Abilities CAA did not analyze the resident's current level of function, goals, or participation in the restorative program, nor did it identify potential negative outcomes. Resident 18, admitted in 2023 with major depression, showed a decline in mood and affect, but the health record lacked an assessment of the cause or contributing factors. The MDS did not include a comprehensive assessment of the resident's mood and behaviors, and no CAA was completed. Staff confirmed the deficiencies in the assessments and documentation for these residents.
Failure to Provide Person-Centered Activity Programs
Penalty
Summary
The facility failed to provide an ongoing person-centered activity program for four sampled dependent residents, leading to a risk of decline in psychosocial well-being and diminished quality of life. Resident 57, admitted with diagnoses including stroke, schizophrenia, and dementia, had no evidence of an Activities care plan completed. Despite having interests in music, reading, and religious activities, Resident 57 was observed mostly alone in her/his room or in the hallway, with no engagement in group or one-on-one activities. Staff confirmed the lack of an activity care plan and awareness of Resident 57's preferences. Resident 17, with a history of stroke and aphasia, also experienced severely impaired cognition. Although the care plan directed staff to assist and encourage participation in activities, no resident-centered interventions were found in the health record. Observations revealed Resident 17 often remained in bed with no engagement in activities, and staff confirmed the lack of in-room activities and awareness of the resident's enjoyment of television and music. Resident 24, cognitively intact and interested in various activities, had a care plan that lacked resident-centered interventions. Observations showed the resident was not engaged in group activities or provided with one-on-one activities. Staff confirmed the absence of activities and the failure to get the resident out of bed for group activities. Additionally, Resident 269, admitted with congestive heart failure, had no assessment of activity preferences completed and was not invited to participate in activities, despite expressing interest. Staff acknowledged the oversight in completing the activity assessment within the required timeframe.
Failure to Provide Licensed Nurse Coverage
Penalty
Summary
The facility failed to ensure that a designated licensed nurse (LN) served as a charge nurse for 36 out of 81 shifts between January 1, 2025, and January 27, 2025. This deficiency was identified through a review of the facility's Direct Care Staff Daily Reports, which showed that multiple shifts across various days lacked LN coverage. Specifically, the absence of LN coverage was noted on several day, evening, and night shifts throughout the month. The Staffing Coordinator confirmed the lack of LN coverage on the specified dates and shifts, and the Administrator was unaware of whether an LN was staffed during these times. This failure placed residents at risk for unmet needs, as the facility did not provide the necessary nursing and related services to ensure resident safety and well-being.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was available for at least eight consecutive hours per day, seven days a week, for 9 out of 27 days reviewed. This deficiency was identified through interviews and record reviews, which revealed that there was no RN coverage for the required hours on specific dates. The Direct Care Staff Daily Reports from January 3 to January 27, 2025, indicated the absence of RN coverage on nine separate days. Staff 17, the Staffing Coordinator, and Staff 1, the Administrator, both acknowledged the lack of RN coverage on the identified days, but no additional information was provided. This failure placed residents at risk for lack of timely RN assessments and care.
Inappropriate Dishware Use Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure residents were treated with dignity, as evidenced by the use of inappropriate dishware for meals. A resident, admitted in 2014 with diagnoses including adult failure to thrive and anxiety, was observed receiving meals in plastic medication glasses and Styrofoam dishware over several days. The resident, who had impairments in both upper extremities, reported difficulty feeding themselves due to the lack of sturdiness of the dishware, resulting in spilled food and drinks. This practice had been ongoing for at least two months, according to the resident. Staff interviews revealed that the use of plastic and Styrofoam dishware was due to regular glassware being lost or unavailable. A CNA confirmed the use of such dishware for multiple residents, while the new Dietary Manager was unaware of the situation until it was brought to his attention. Upon conducting a walk-through, the Dietary Manager confirmed the widespread use of non-dignified dishware, acknowledging it was not appropriate or home-like for the residents.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform residents and/or their responsible parties about the risks and benefits of psychotropic medications and did not obtain consent for their use. This deficiency was identified for one of five sampled residents, who was admitted with a diagnosis of generalized anxiety disorder. The resident's Medication Administration Record (MAR) indicated they were receiving Citralopram Hydrobromide and Aprazolam as prescribed by their physician. However, there was no documentation in the resident's health record to show that the resident or their representative was informed about the risks and benefits of these medications, nor was there evidence of consent being obtained. The Director of Nursing Services (DNS) confirmed that it was expected for nursing staff to review the risks and benefits with residents before administering the medications, which did not occur in this case.
Resident Excluded from Care Planning Process
Penalty
Summary
The facility failed to ensure that a resident was included in the development and implementation of their person-centered care plan. The resident, who was admitted with diagnoses of myocardial infarction and a fractured leg, was cognitively independent and their own responsible party. Despite this, there was no evidence in the clinical record that the resident was involved in the care planning process. The resident confirmed that facility staff did not consult them about their care plan, and they were unaware of its contents. Staff members, including an RNCM and the DNS, acknowledged the lack of documentation and involvement of the resident in the care planning process, which was expected to occur within 72 hours of admission.
Failure to Assess Self-Administration of Medication
Penalty
Summary
The facility failed to assess the appropriateness of self-administration of medication for two residents, which placed them at risk for unsafe medication administration. Resident 18, who was admitted in 2023 with a diagnosis of stroke, was observed with a bottle of Fluticasone Propionate Nasal spray within reach on their overbed table. A review of the resident's health record revealed that no self-administration assessment had been completed to determine the resident's ability to safely self-administer the nasal spray. Staff confirmed that the resident had not been assessed for self-medication and that the medication should not have been left in the room. Similarly, Resident 60, admitted in December 2024 with chronic obstructive pulmonary disease (COPD), was found with an albuterol sulfate inhaler on their bedside table. The resident stated that the inhaler was albuterol sulfate, yet no assessment for self-administration of medications had been performed. Staff confirmed that Resident 60 had not been assessed for safety with self-administration of the inhaler, and it should not have been left with the resident before determining their ability to self-administer the medication safely.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for a resident diagnosed with Aphasia, which affects communication abilities. The resident's care plan, dated 1/29/25, directed staff to keep the call light accessible. However, observations on 1/29/25 at 9:31 AM and 10:47 AM revealed that the call light was wrapped around the base of the bed's head frame, making it unreachable. During a Resident Council meeting on 1/30/25, residents reported that their call lights were often tied to the back of their beds, preventing them from calling for assistance. Staff 8, a CNA, confirmed on 1/30/25 that the call light was not within reach. On 2/3/25, Staff 2, the DNS, also confirmed the call light's inaccessibility and stated that the care plan should have been followed.
Failure to Provide SNF ABN Notification
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) to a resident, identified as Resident 34, who was admitted with Medicare A benefits. The Notice of Medicare Non-Coverage (NOMNC) indicated that the resident's Medicare Part A benefits ended on October 14, 2024. However, the resident remained in the facility and was financially responsible for their care from October 15, 2024, until December 1, 2024. There was no documentation showing that the SNF ABN notification was provided to the resident or their representative to inform them of the daily out-of-pocket costs. On January 29, 2025, Staff 2, the Director of Nursing Services (DNS), reported that the facility was not providing SNF ABN notifications to residents or their representatives, despite the expectation that they should be informed of such costs.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to potential unmet care needs. Resident 25, admitted in 2018 with diabetes, was observed to be alert and oriented, yet their 12/21/24 Quarterly MDS inaccurately indicated they were rarely/never understood and omitted a diagnosis for opioid medication use. This was inconsistent with their 3/20/24 Annual MDS, which showed a BIMS score of 15 and a chronic pain diagnosis. Staff 2 acknowledged the inaccuracy. Similarly, Resident 45, admitted in 4/2024 with anxiety disorder, had discrepancies in their MDS assessments regarding the use of corrective lenses. The 8/28/24 MDS noted the use of glasses, while the 12/1/24 MDS did not, despite the resident being observed wearing glasses and confirming long-term use. Staff 2 confirmed the inaccuracy in the most recent assessment.
Failure to Conduct Accurate PASARR for Resident with Mental Health Needs
Penalty
Summary
The facility failed to conduct a new and accurate Level I PASARR (Pre-Admission Screening and Resident Review) for a resident who was admitted with diagnoses including Bi-Polar Disorder, Major Depressive Disorder, and anxiety. The initial PASARR I, completed by the hospital upon admission, indicated no serious mental illness. However, the resident's care plan included interventions for safety and behavioral concerns, such as administering antidepressant, antipsychotic, and mood stabilizer medications, and reporting agitation, aggression, or depression to nursing staff. The resident also experienced hallucinations, which were documented in a social services summary. Despite these indicators, there was no evidence in the resident's health record of a corrected Level I PASARR or a referral for a Level II PASARR for behavioral services. Observations over several days noted the resident self-isolating in their room. Staff members, including the Activity Director/Social Service Director and the DNS, acknowledged the resident's behaviors and expressed an expectation that a Level II PASARR should have been completed. This oversight placed the resident at risk for delayed care and lack of necessary services to support their mental health needs.
Failure to Develop Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop a comprehensive, resident-centered baseline care plan within 48 hours of admission for two residents, leading to unmet care needs. Resident 220, admitted with multiple complex medical conditions including acute and chronic respiratory failure, dysphagia, and high fall risk, had a baseline care plan that only addressed nutritional concerns. This omission left significant care needs such as oxygen therapy, BIPAP use, and wound care unaddressed. Staff confirmed that the baseline care plan did not reflect the resident's active problems, indicating a lack of guidance for staff on the resident's care requirements. Similarly, Resident 41, admitted with severe cognitive impairment and orthostatic hypotension, did not have a baseline care plan developed during their initial stay. This oversight occurred despite the resident's need for assistance with transfers and the absence of a history of elopement. The lack of a care plan was acknowledged by staff after the resident experienced a fall resulting in a hip fracture, which required hospitalization. The absence of a baseline care plan for both residents highlights a failure in the facility's process to ensure immediate and comprehensive care planning upon admission.
Failure to Assist Resident with Glasses Repair
Penalty
Summary
The facility failed to provide necessary assistance for the repair of a resident's glasses, which were damaged as a result of a fall within the facility. The resident, who was admitted in April 2024 with a diagnosis of anxiety disorder, was observed wearing glasses with a significant scratch on the right lens, impairing their vision. This issue was noted during an observation in January 2025, where the resident reported that the scratch had been present for a long time, causing hazy vision. Staff confirmed that the damage occurred due to a fall at the facility, and acknowledged that the glasses should have been repaired or replaced.
Failure to Provide Regular Restorative Nursing Services
Penalty
Summary
The facility failed to provide regular restorative nursing services to maintain or improve the range of motion (ROM) and mobility for two residents. Resident 33, admitted with a stroke and hemiparesis, was cognitively intact and expressed a desire to be active. Despite having a care plan that included restorative nursing services three to five times a week, the resident reported not receiving these services regularly due to the restorative aide being reassigned to work as a CNA. This lack of regular services led to increased difficulty in walking and pain during dressing. Staff confirmed the reassignment of the restorative aide and acknowledged the absence of a system to track restorative services. Similarly, Resident 18, also admitted with a stroke, had a care plan for impaired mobility that included passive ROM exercises and a power wheelchair program. However, the resident expressed a desire to be more active and out of bed, indicating a lack of regular restorative services. Staff confirmed that due to staffing issues, restorative services were often unavailable, and there was no system in place to track the services provided or resident participation. The DNS admitted to the absence of a consistent restorative program and expected Resident 18 to receive services as planned.
Failure to Update Pain Medication Instructions for Resident
Penalty
Summary
The facility failed to update pain medication instructions to include resident-centered dosing for a resident with anxiety, cancer, and an abscess of the lower limb. The resident, who had mild cognitive impairment and experienced daily pain, was prescribed oxycodone HCl 5 MG to be taken three times a day as needed. However, the Comprehensive Care Plan did not address the resident's specific pain related to the lower extremity infection or the need for pain control during dressing changes. This oversight led to inconsistent interpretation of PRN orders by nursing staff, resulting in the resident not receiving timely pain medication. The resident reported not always receiving oxycodone timely, as nursing staff interpreted the TID dosing as three times a day or every 8 hours, despite the provider's note indicating a minimum time between doses could be three hours. On one occasion, the resident did not receive a bedtime dose of oxycodone and was given Tylenol instead, which did not relieve the pain. The Medication Administration Record (MAR) showed a gap in dosing, with the resident not receiving another dose until the following morning. Despite the provider's clarification in the progress notes, the resident's MAR and Care Plan were not updated to address the timing of the pain medication.
Failure in Dialysis Communication and Monitoring
Penalty
Summary
The facility failed to ensure proper dialysis services and communication with the dialysis provider for a resident with end-stage renal disease. The facility's policy required communication with the dialysis center through a transfer form and the exchange of lab results, weights, and other pertinent information. However, for the resident in question, there was only one partially completed communication report, and no evidence that the facility received or sought the necessary information from the dialysis center for any of the resident's nine dialysis treatments. The resident, who was admitted with diagnoses including diabetes and end-stage renal disease, reported that upon returning from dialysis, nursing staff did not perform an assessment or check the dialysis port. Staff interviews confirmed that the required communication reports were not completed, and the necessary assessments were not conducted upon the resident's return from dialysis. This lack of communication and assessment placed the resident at risk for dialysis complications and delayed treatment.
Failure to Act on Pharmacy Recommendations for PRN Antipsychotic Use
Penalty
Summary
The facility failed to respond to pharmacy recommendations regarding the use of PRN antipsychotic medication for a resident. The resident, admitted in May 2019, had diagnoses of major depression, schizophrenia, and anxiety disorder. The December 2024 and January 2025 Medication Administration Records (MARs) showed an order for Seroquel, an antipsychotic, to be administered every six hours as needed for agitation and anxiety, with a start date of December 2, 2024, and an end date of January 28, 2025, when the order was changed to a 14-day duration. However, there was no evidence that the December pharmacy review was completed or acted upon. The Consultant Pharmacist stated that reviews and notes were sent to the prescriber on December 20, 2024, and January 27, 2025, regarding the need for a 14-day limit and to ensure evidence of in-person physician visits.
Failure to Limit PRN Antipsychotic Use to 14 Days
Penalty
Summary
The facility failed to ensure that the PRN use of an antipsychotic medication, Seroquel, was limited to 14 days for a resident diagnosed with major depression, schizophrenia, and anxiety disorder. The resident was admitted in 2019 and had an order for Seroquel 25 mg every six hours PRN for agitation/anxiety, in addition to scheduled doses. The medication order started on December 2, 2024, and was not adjusted to a 14-day duration until January 28, 2025. During December 2024, the PRN dose was administered 15 times, and in January 2025, it was used eight times. This oversight was confirmed by Staff 13, a Corporate Nurse Consultant, on January 30, 2025, indicating a failure to adhere to the 14-day limitation for PRN antipsychotic use.
Inaccurate Documentation of Physician Orders for Two Residents
Penalty
Summary
The facility failed to accurately document physician orders for two residents, leading to discrepancies in their care. Resident 220, who was admitted with conditions including dysphagia and malnutrition, was supposed to receive a mechanical soft diet as per the hospital discharge orders. However, the facility's records incorrectly documented the diet as minced and moist textures, resulting in the resident receiving pureed foods, which they did not prefer and refused to eat. This error was acknowledged by the staff, who confirmed that the transcription of the diet orders was incorrect. Similarly, Resident 269, admitted with a diagnosis of atherosclerosis, was instructed to be weight-bearing as tolerated on their left lower extremity according to hospital discharge instructions. However, the facility's nursing evaluation and care plan inaccurately documented the resident as non-weight-bearing. This inconsistency led to confusion, as the resident received conflicting instructions from nurses and therapists. The Director of Nursing Services confirmed the error in the documentation of weight-bearing precautions.
Deficiencies in Resident Care Plans for Medication Management and Behavioral Interventions
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, which led to deficiencies in addressing their specific needs. Resident 118, admitted with diagnoses including epilepsy, anxiety disorder, and depression, had an incomplete care plan that did not address the use of PRN diazepam for auras or seizure activity, nor did it consider potential cognitive changes or behavioral needs identified in care conference notes. Despite the resident expressing concerns about their medication, the care plan lacked clarity on how the anxiety disorder manifested and did not provide a person-centered approach to medication management. Similarly, Resident 24, diagnosed with Bipolar Disorder, Major Depression, and anxiety, had a care plan that failed to address how their diagnoses and behaviors presented. The care plan did not provide specific interventions for staff to use when the resident exhibited behaviors such as visual hallucinations. Staff acknowledged the absence of resident-centered interventions in the care plan, which did not adequately address the resident's behavior related to mental illness.
Deficiencies in Skin Care and Medication Management
Penalty
Summary
The facility failed to provide care and treatment as care planned for a resident with skin conditions and did not ensure person-centered medication management for another resident. One resident, admitted in 2018 with diabetes, was observed with significant bruising and an abrasion on their lower right leg and arm. Despite these observations, there were no documented skin assessments, monitoring, or treatments for the bruising and abrasion, which was confirmed by the Director of Nursing Services (DNS). Another resident, admitted in August 2024 with a history of surgical repair of a fractured hip, epilepsy, depression, and anxiety disorder, experienced issues with medication management. The resident expressed frustration over medication administration, particularly regarding the concurrent use of sedating medications. Nursing staff hesitated to administer these medications simultaneously due to concerns about sedation, despite the resident's description of auras that could precede seizures. The resident's care plan was not updated to reflect specific administration instructions, leading to conflicts between the resident and nursing staff.
Inaccurate Staffing Information Posting
Penalty
Summary
The facility failed to post accurate and complete staffing information, as evidenced by a review of the Direct Care Staff Daily Reports from January 1 to January 27, 2025. During this period, 17 days were identified where portions of the staffing forms were left blank or contained inaccuracies, such as missing daily census data, absent signatures, and incorrect numbers of working staff. On January 27 and January 28, 2025, the Care Staff Daily Reports displayed incorrect information, including incomplete shifts and outdated data from the previous day. On January 30, 2025, the Administrator acknowledged that many of the reviewed reports were incomplete and inaccurately documented the number of staff working on several days.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
