West Hills Health & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Portland, Oregon.
- Location
- 5701 Sw Multnomah Blvd, Portland, Oregon 97219
- CMS Provider Number
- 385112
- Inspections on file
- 19
- Latest survey
- May 1, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at West Hills Health & Rehabilitation during CMS and state inspections, most recent first.
Staff failed to follow required hygiene and food safety protocols, including not wearing proper hair restraints, neglecting hand hygiene, and not labeling or discarding undated food items in kitchen and unit refrigerators. Additionally, ice machines were found with mold, slime, and improper drainage, and were used to serve residents. Staff acknowledged these ongoing issues and inconsistent responsibilities for food and equipment sanitation.
A resident with spinal stenosis was found with a cup of multiple medications left on the bedside table without an assessment for safe self-administration, contrary to facility policy. The resident reported waiting for someone to identify the medications, and staff confirmed the medications were left after the resident was not present during the medication pass. The DNS acknowledged that no assessment had been completed and medications should not have been left in the room.
The facility did not obtain or maintain documentation of advance directives for three residents with complex medical conditions, despite care plans and conference notes indicating these directives were in effect or reviewed. Residents were either unsure about their advance directive status or confirmed the facility did not have a copy, and staff interviews revealed that necessary follow-up to secure these documents was not performed.
A facility failed to provide necessary training for a resident on self-administering an anticoagulant medication before discharge. Despite the resident's care plan requiring education on medication administration, there was no documentation of such training. Staff confirmed the lack of documentation and training, acknowledging the facility's responsibility to ensure residents are prepared for medication administration post-discharge.
A resident with hypothyroidism and hypertension did not receive their prescribed levothyroxine and spironolactone due to a failure in medication administration procedures. An LPN was unaware of the medication schedule and did not report the missed doses to the RCM, DNS, or physician. The DNS confirmed the oversight and highlighted the responsibility of oncoming nurses to review previous medication passes.
The facility failed to ensure sufficient dietary staff, resulting in meals being served late and sometimes cold. Staff and the Resident Council President confirmed ongoing issues with meal timeliness, particularly on weekends, due to staffing shortages.
A resident with encephalopathy and dementia was given a hot cup of tea without proper supervision, resulting in a first-degree burn. The care plan required one-to-one supervision during meals, but the assigned agency staff was not present at the time of the incident.
The facility failed to ensure meals were served in a palatable and appetizing manner, leading to multiple complaints from residents and staff. Issues included cold, tasteless food, inconsistent portions, and poor food quality, as confirmed by a test tray and various interviews.
Deficient Food Safety and Sanitation Practices in Kitchen and Ice Machines
Penalty
Summary
Facility staff failed to adhere to proper personal hygiene and food safety protocols in the kitchen and unit food storage areas. Observations included kitchen staff preparing meals without appropriate hair and beard restraints, and staff failing to perform hand hygiene after glove changes or before food handling. Despite signage reminding staff of hand hygiene requirements, these practices were not consistently followed. Additionally, food items in the kitchen refrigerator and unit refrigerators were found to be undated or improperly labeled, including raw chicken, sliced tomatoes, banana cream pie, sushi, and other unidentifiable foods. Staff provided conflicting information regarding responsibility for discarding undated food, and acknowledged that undated items should be discarded but were not consistently removed. Further deficiencies were observed in the maintenance and sanitation of facility ice machines. One ice machine was found draining into a container of dirty water that also contained a sealed food item, and the interior of the machine had visible black spotting. Another ice machine had drain pipes covered in dark, slimy substances and black mold, with pink mold present where ice was dispensed. Staff were observed using these machines to provide ice to residents. Maintenance and dining services staff confirmed the presence of debris, mold, and slime, and acknowledged responsibility for cleaning the machines, but the issues persisted at the time of survey.
Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was properly assessed for the safe self-administration of medications, as required by its own policy. The policy states that a resident may only self-administer medications after the interdisciplinary team determines which medications can be safely self-administered. However, a review of the resident's record showed no assessment had been completed for self-administration of medications. During observations, the resident was found alone in their room with a cup containing multiple medications on the bedside table. The resident stated they were waiting for someone to tell them what the medications were. Staff confirmed that the medications had been left in the resident's room after the resident was not present during the medication pass. The Director of Nursing Services also confirmed that the resident had not been assessed for self-administration and that medications should not have been left in the room.
Failure to Obtain and Document Advance Directives for Multiple Residents
Penalty
Summary
The facility failed to obtain and maintain documentation of advance directives and health care decisions for three residents with significant medical conditions, including chronic inflammatory demyelinating polyneuritis, sepsis with metabolic encephalopathy, and stroke. For each resident, care plans and care conference notes indicated that advance directives were in effect or had been reviewed, but no actual advance directive documents were found in the clinical records. Interviews with the residents revealed that they either had not completed an advance directive, were unsure if one was completed, or believed the facility did not have a copy. Staff interviews confirmed that there was no advance directive on file for any of the three residents, and the Social Services Coordinator acknowledged that follow-up to obtain or confirm these documents had not occurred. In one case, documentation indicated that a power of attorney (POA) was to be contacted, but there was no evidence this was done. The Executive Director stated that blank advance directive forms were provided at admission, but follow-up and documentation were not consistently completed.
Failure to Provide Medication Administration Training Before Discharge
Penalty
Summary
The facility failed to provide necessary education and training for the self-administration of an anticoagulant subcutaneous medication prior to the discharge of a resident. The facility's discharge planning policy required the development and implementation of an effective discharge planning process, which included evaluating the resident's discharge needs and providing continuous education to the resident and their family. However, the facility did not adhere to this policy for a resident who was admitted with a left femur fracture and stroke and was receiving subcutaneous injectable anticoagulant therapy. The resident's care plan included interventions for training and education on medication administration, but there was no documentation indicating that the resident or their representative received this training before discharge. The resident was discharged with the prescription still in active use, and staff members confirmed the lack of documentation and training. The LPN responsible for discharge planning and the RNCM both acknowledged the absence of documentation and training, and the DNS confirmed the facility's responsibility to ensure residents are trained on medication administration prior to discharge.
Failure to Administer Prescribed Medications
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically for one resident who was not administered their prescribed medications. The resident, who had diagnoses of hypothyroidism and hypertension, was ordered to receive levothyroxine and spironolactone at 6 AM before meals. However, a review of the resident's December Medication Administration Record (MAR) revealed that these medications were not administered as ordered. Staff 6, an LPN, confirmed that the resident did not receive their thyroid or blood pressure medications and admitted to being unaware of the timing for the administration of these medications. Staff 6 also stated that it was not her responsibility to review previous medication passes to ensure completion by the last shift and did not report the missed medication administration to the Resident Care Manager (RCM), Director of Nursing Services (DNS), or the physician. The DNS confirmed that the oncoming nurse failed to review the previous medication pass and emphasized that it is the facility's expectation for any nurse discovering a medication error to report it and file an incident report.
Dietary Staffing Shortages Lead to Late Meal Service
Penalty
Summary
The facility failed to ensure sufficient dietary staff were available to deliver food service in a timely manner, which placed residents at risk for unmet nutritional needs. A public complaint was made to the state agency alleging that all meals were served late daily, and this issue had persisted for several months. The Resident Council President confirmed that meals were always served late and sometimes cold. Staff interviews revealed that the dining room was served first, followed by different halls, with the skilled hall being served last. Staff members, including a cook and CNAs, acknowledged ongoing staffing shortages, particularly in the dietary department, which resulted in meals being served up to 45 minutes late, especially on weekends. The facility's Administrator also acknowledged the issue and mentioned the process of hiring a new Dietary Manager.
Failure to Implement Supervision for Resident with Dementia
Penalty
Summary
The facility failed to implement care plan interventions to ensure adequate supervision was provided to prevent accidents for a resident with encephalopathy and dementia. The resident's care plan required one-to-one supervision during meals and specified that staff should not leave cups in front of the resident without supervision. However, on one occasion, the resident was given a hot cup of tea without proper supervision, resulting in the resident dropping the cup and sustaining a first-degree burn on the left thigh. Staff interviews revealed that an agency staff member was assigned to supervise the resident but was not present at the time of the incident. A CNA observed the resident about to throw the cup but left the dining room for about 30 seconds, during which the incident occurred. The DNS confirmed that the resident sustained a first-degree burn with no blisters as a result of the liquid spill.
Failure to Ensure Palatable and Appetizing Meals
Penalty
Summary
The facility failed to ensure meals were served in a palatable and appetizing manner for two sampled residents, leading to unmet nutritional needs. The facility's Food Temperature policy, revised in August 2023, stated that food should be transported quickly to maintain appropriate temperatures. However, multiple complaints were documented, including from the Resident Council notes in March 2024, which indicated that food was always cold, tasteless, and portions were inconsistent. Resident 105, admitted in 2022 with acute cystitis and weakness, reported that the food was terrible, often resorting to peanut butter and jelly sandwiches and oatmeal. Resident 106, admitted in 2023 with transverse myelitis and Hepatitis B, stated that the food quality had declined after menu changes, leading them to eat mostly salads due to poor food quality. The Resident Council President and several CNAs corroborated these complaints, noting that food was often late, cold, too salty, overcooked, and generally unpalatable. A test tray sampled on May 7, 2024, revealed that the shrimp was lukewarm and not fully cooked, the rice was bland, and the sautéed vegetables were mushy and unappetizing. The National Culinary Director acknowledged the complaints and mentioned that the company was in the process of hiring a new dietary manager. The facility administrator also acknowledged the multiple complaints about the food and confirmed efforts to hire a new dietary manager. These observations and interviews indicate a systemic issue with food quality and temperature, affecting the residents' nutritional intake and overall satisfaction with their meals.
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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