Village Manor Of Cascadia
Inspection history, citations, penalties and survey trends for this long-term care facility in Wood Village, Oregon.
- Location
- 2060 Ne 238th Drive, Wood Village, Oregon 97060
- CMS Provider Number
- 38E174
- Inspections on file
- 21
- Latest survey
- August 12, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Village Manor Of Cascadia during CMS and state inspections, most recent first.
A resident with dementia and a history of falls was left unattended in the shower room without required supervision, a shower bench, or non-skid footwear. The resident was found by housekeeping staff after sustaining multiple pelvic fractures and internal bleeding, and staff confirmed that the care plan interventions to prevent falls were not followed.
A resident with a history of schizoaffective disorder struck another resident with psychosis in the face while the latter was sleeping. Staff responded to yelling, separated the residents, and called EMTs. The assaulted resident was not physically injured but reported feeling scared and uncomfortable sharing a room with the aggressor. Staff and documentation confirmed the incident met the definition of abuse.
A resident with schizophrenia and traumatic brain injury was forcefully shoved and thrown against a wall by another resident with dementia and delirium. Staff intervened and separated the residents, but the LPN involved, being new, did not submit the required abuse report to the State Agency within the mandated timeframe, despite assistance from the DNS and another nurse.
A resident with borderline personality disorder was unable to independently operate their bedside light due to a shortened chain, leading to frustration and repeated requests for staff assistance. Staff had inconsistent knowledge about the resident's ability to use the light, and the care plan did not address the modification. The chain had been shortened for safety, but key staff were unaware this prevented the resident from using the light without help.
A resident with a history of anxiety, hallucinations, and disorientation was repeatedly administered haloperidol without documented indications or behaviors warranting its use. Multiple LPNs gave the antipsychotic for reasons such as agitation or difficulty sleeping, but failed to record specific symptoms, non-pharmacological interventions, or the effectiveness of the medication, resulting in the use of unnecessary psychotropic medication as a chemical restraint.
A resident with multiple psychiatric diagnoses was prescribed several psychotropic medications, but the facility did not include any interventions for the use of these medications in the resident's care plan. Review of the clinical record and confirmation by the DNS showed no resident-specific interventions were documented.
A resident with a history of stroke and swallowing difficulties experienced a choking episode during dinner that required the Heimlich maneuver by an LPN. Despite this event, the resident's diet was not immediately downgraded, and the speech-language pathologist was not notified until several days later. The delay in assessment and intervention following the choking incident led to the deficiency.
A resident with cognitive impairment and a care plan requiring smoking gloves to prevent burns was observed smoking without the gloves. The resident reported that staff did not offer the gloves, and staff confirmed the omission, resulting in a failure to follow the care plan for accident prevention.
Two residents with PTSD did not receive trauma-informed care as required by facility policy. Staff failed to complete trauma assessments or develop care plans addressing trauma triggers, and were unaware of the residents' trauma histories or specific needs. Both residents confirmed that trauma triggers and histories were not discussed with them.
A resident with anxiety, hallucinations, and disorientation was prescribed Olanzapine. The pharmacist recommended updating the medical record with specific symptoms, consideration of other causes, and use of nonpharmacological interventions if the antipsychotic was to continue. These recommendations were not followed, and the required documentation was missing from the clinical record.
Two residents received unnecessary medications when staff failed to follow physician orders to withhold midodrine for elevated SBP and senna for loose stools. Despite clear parameters, both medications were administered on multiple occasions when they should have been held, as confirmed by MAR reviews and staff interviews.
A resident with dementia and a history of frequent falls did not receive a physician-ordered PT evaluation after staff determined therapy was not appropriate due to recent prior therapy. The decision was not communicated to the provider, and the ordered service was not completed, leaving the resident without the specialized rehabilitative intervention intended to address fall risk.
Failure to Follow Fall Prevention Care Plan During Bathing
Penalty
Summary
A deficiency occurred when the facility failed to implement care plan interventions designed to prevent falls for a resident with dementia who was identified as a fall risk. The resident's care plan specified the need for supervision and touch assistance during bathing, use of a shower bench or bathtub, and wearing non-skid footwear when up. Despite these interventions, the resident was found unattended in the shower room by housekeeping staff, not fully clothed, without socks or shoes, and without a shower bench present. The resident was in a shower stall rather than a bathtub, and staff interviews confirmed that the care plan was not followed. As a result of these failures, the resident sustained multiple complex pelvic fractures and internal bleeding, requiring transfer to the hospital for evaluation. Staff statements and administrative confirmation indicated that the resident was left alone in the shower room, and the required safety equipment and supervision were not provided at the time of the incident.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
A resident with schizoaffective disorder was admitted to the facility and shared a room with another resident diagnosed with psychosis. On the night of the incident, staff heard yelling and discovered the first resident standing over the second resident's bed, having struck the resident in the face while the latter was sleeping. The assaulted resident reported being woken by the physical contact and responded by kicking the aggressor away. Staff intervened to separate the residents and emergency medical technicians were called to the scene. The assaulted resident did not sustain physical injuries but expressed fear and discomfort about sharing a room with the aggressor. Staff confirmed that the incident involved one resident hitting another and acknowledged that it met the definition of abuse. The incident was reported to the State Survey Agency, and facility documentation corroborated the sequence of events, including the lack of injury and the emotional impact on the assaulted resident.
Failure to Timely Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency within the mandated timeframe for one resident. According to the facility's policy, allegations of abuse, including physical altercations between residents, must be reported to the administrator immediately and to the state agency within two hours if there is alleged abuse or serious bodily injury. In this incident, a resident with schizophrenia and a history of traumatic brain injury was forcefully shoved and thrown against a wall by another resident with dementia and delirium. Staff intervened and separated the residents, and the incident was documented in the facility's FRI. However, the FRI was not submitted to the State Agency within the required timeframe. The LPN involved was new and unfamiliar with the FRI process, so she sought assistance from the DNS and another nurse, which contributed to the delay. The DNS confirmed that she was in contact with the LPN multiple times regarding the incident, but acknowledged that the report was not completed and submitted as mandated.
Failure to Ensure Resident Access to Bedside Light
Penalty
Summary
A deficiency was identified when a resident with a diagnosis of borderline personality disorder was found to be unable to independently operate the bedside light in their room due to a short three to four inch chain. The resident reported frustration at being unable to turn the light on or off without assistance, requiring them to use the call bell for help. The resident's care plan did not indicate any need for a shortened chain on the bedside light. Staff interviews revealed inconsistent awareness of the resident's ability to use the light. One CNA believed the resident could use a reacher to operate the light, while an LPN stated the resident was not capable of doing so and frequently called for assistance. The RN Case Manager was unaware of the shortened chain, and the Environmental Services Director explained the chain had been shortened for safety reasons after the resident previously pulled on it to reposition, but was unaware the resident could no longer use the light independently. The Director of Nursing Services confirmed knowledge of the short chain but was not aware the resident required help to operate the light.
Failure to Prevent Unnecessary Use of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from chemical restraints and unnecessary psychotropic medication use. The resident, admitted with diagnoses including anxiety, hallucinations, and disorientation, was prescribed haloperidol as needed for hallucinations or aggression. However, medication administration records, behavior monitoring, and progress notes showed that haloperidol was given on multiple occasions without documented indications for use. Nursing staff administered the medication for reasons such as difficulty sleeping, agitation, or being difficult to control, but did not consistently document the specific behaviors or symptoms that warranted its use. Interviews with several LPNs revealed uncertainty about the reasons for administering haloperidol and a lack of documentation regarding the resident's behaviors or the effectiveness of the medication. The Director of Nursing Services confirmed that haloperidol should only have been given for aggression or hallucinations and that staff were expected to document the specific behaviors, non-pharmacological interventions attempted, and the outcome of the medication administration. The absence of this documentation and the administration of haloperidol without clear indications constituted a failure to prevent the use of unnecessary psychotropic medications and chemical restraints.
Failure to Develop Care Plan Interventions for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop comprehensive care plans that included interventions for the use of psychotropic medications for one resident who was admitted with diagnoses of anxiety, hallucinations, and disorientation. Physician orders for this resident included multiple psychotropic medications such as Buspirone, Lamotrigine, Mirtazapine, Duloxetine, Olanzapine, and Haloperidol, each prescribed for specific symptoms including irritability, mood stabilization, insomnia, depression, and hallucinations. A review of the resident's care plan dated 2/24/25 revealed no documented interventions addressing the use of these psychotropic medications. Additionally, there was no evidence in the resident's health record of any resident-specific interventions related to psychotropic medication use. This lack of documentation was confirmed by the Director of Nursing Services during an interview.
Failure to Timely Assess and Intervene After Choking Incident
Penalty
Summary
A resident with a history of stroke was admitted to the facility and had documented issues with coughing and choking during meals and when swallowing medications. The resident was on a dental/mechanical soft texture diet with nectar thick liquids per physician orders. On one occasion, the resident choked during dinner, requiring the Heimlich maneuver to be performed by an LPN, after which the resident recovered. Despite this significant choking episode, the resident's diet was not immediately downgraded, and there was no evidence that the speech-language pathologist was notified following the incident. The LPN involved acknowledged that the resident's diet should have been changed to puree at the time of the choking event but did not take this action. The Director of Rehabilitation was not informed of the choking incident until three days later, at which point the diet was downgraded and a consultation with the speech-language pathologist was initiated. The Director of Nursing Services also confirmed that the diet should have been downgraded immediately after the choking episode. The delay in assessment and intervention following the resident's change in condition constituted the deficiency.
Failure to Provide Care Planned Smoking Safety Interventions
Penalty
Summary
A deficiency occurred when a resident with Wernicke's encephalopathy and dementia, who was care planned to wear smoking gloves while smoking to prevent burns, was observed smoking in the designated area without the required gloves. The resident's care plan and quarterly smoking evaluation both specified the use of smoking gloves, and the most recent MDS assessment indicated moderate cognitive impairment. During the observation, the resident stated that staff did not offer the smoking gloves, and a CNA confirmed the resident was not wearing them as required. The Director of Nursing Services acknowledged that staff failed to provide the gloves as outlined in the care plan.
Failure to Provide Trauma-Informed Care and Assessment
Penalty
Summary
The facility failed to provide trauma-informed care for two residents with behavioral and emotional care needs, both of whom had diagnoses including PTSD. According to the facility's own Trauma Informed Care Policy, residents should be screened for traumatic events, and individualized care plans should be developed to address trauma triggers and interventions. However, for both residents, there was no evidence in their clinical records that trauma assessments were completed or that care plans addressing trauma triggers were developed. Staff interviews confirmed a lack of awareness regarding the residents' trauma histories or potential triggers, and social services staff acknowledged that required trauma screenings and care planning had not been completed for these residents. One resident, admitted with schizophrenia and PTSD, reported experiencing auditory hallucinations and distress but could not recall being asked about trauma triggers. Staff members were unaware of any specific triggers or interventions in place for this resident. The second resident, admitted with major depressive disorder and PTSD, also had no documented trauma assessment or care plan. This resident stated that no one had discussed the cause of their PTSD or potential triggers, and staff were similarly unaware of any trauma-related needs or interventions. The lack of trauma-informed assessments and care planning placed these residents at risk for re-traumatization.
Failure to Implement Pharmacist Recommendations for Antipsychotic Use
Penalty
Summary
The facility failed to act upon a pharmacist's recommendations for a resident who was prescribed Olanzapine, an antipsychotic medication, for hallucinations. The pharmacist had recommended that, if the antipsychotic was to be continued, the medical record should be updated to include a list of symptoms or target behaviors and their impact on the resident, documentation that other causes and medications had been considered, evidence of individualized nonpharmacological interventions, and ongoing monitoring. A review of the resident's clinical record showed that these recommendations were not implemented, as there was no documentation of specific target behaviors, their impact, consideration of other causes or medications, or individualized nonpharmacological interventions. The Director of Nursing Services confirmed that the pharmacist's recommendations were not followed.
Failure to Withhold Unnecessary Medications as Ordered
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary medications, specifically bowel and antihypotensive drugs. One resident with a diagnosis of hypotension was prescribed midodrine to be administered three times daily, with clear physician orders to hold the medication if the systolic blood pressure (SBP) exceeded a specified threshold. Despite these orders, the medication was administered on at least 24 occasions when the resident's SBP was above the hold parameter, as confirmed by medication administration records and staff interviews. Nursing staff acknowledged that the medication should have been withheld on these occasions but was not. Another resident with a history of bipolar disorder and hip fracture was prescribed senna for constipation, with instructions to hold the medication for loose stools. Review of medication administration and bowel movement records showed that the resident continued to receive senna even after experiencing multiple episodes of loose or watery stools, as indicated by type 6 and type 7 bowel movements. Staff interviews confirmed that the medication should have been withheld until normal stool consistency returned, but this was not done, and the medication was administered daily regardless of bowel movement consistency.
Failure to Provide Ordered Physical Therapy Evaluation for Resident with Frequent Falls
Penalty
Summary
A deficiency occurred when the facility failed to provide therapy services as ordered for a resident with a history of frequent falls and a diagnosis of dementia. The resident had multiple falls in recent months, with eight falls documented in one month, and was known to be impulsive and prone to self-transferring. A physician's order was written for a physical therapy (PT) evaluation due to these frequent falls. However, the PT evaluation was not completed as ordered. Staff interviews revealed that the therapy manager determined PT was not appropriate because the resident had recently completed therapy, but this decision was not discussed with the resident's provider. Further review showed that the interdisciplinary team assumed the provider was informed of the decision to not proceed with the PT evaluation, but there was no evidence of direct communication with the provider regarding the appropriateness of the order. The failure to follow the physician's order for a PT evaluation left the resident without the specialized rehabilitative services that had been deemed necessary to address their risk for falls.
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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