Willowbrook Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Pendleton, Oregon.
- Location
- 707 Sw 37th Street, Pendleton, Oregon 97801
- CMS Provider Number
- 385201
- Inspections on file
- 20
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Willowbrook Post Acute during CMS and state inspections, most recent first.
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 did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
Medication refrigerator temperatures were not consistently monitored or recorded as required, with multiple instances of missed checks and temperatures falling below the acceptable range. Nursing staff and the Environmental Services Director confirmed lapses in monitoring and documentation, and the Director of Nursing Services acknowledged the deficiencies.
The facility did not provide enough nursing staff to meet the care needs of residents, resulting in long call light response times, missed ADL care, and delays in assistance for residents requiring two-person transfers, ostomy care, and other high-acuity services. Staff and residents reported frequent understaffing, especially during night and weekend shifts, leading to incidents such as falls, missed showers, and residents waiting extended periods for help.
A resident prescribed oxycodone for pain management had a card of medication go missing after staff failed to properly count narcotics during shift changes. The medication was not recovered, and the incident was determined to be misappropriation of resident property.
Three residents with moderate cognitive impairment were found with medicated powders and lotions at their bedside without documented assessments or physician orders for self-administration. Staff confirmed that facility policy requires both an assessment and a physician order for residents to self-administer medications, but these steps were not completed, resulting in unauthorized access to medications.
A resident with a history of stroke and one-sided impairment used a motorized wheelchair with a self-releasing seatbelt, but no assessment was completed to determine if the seatbelt functioned as a restraint. Staff interviews revealed uncertainty about whether the resident could independently latch the seatbelt and whether an assessment had been performed, despite facility policy requiring such evaluations.
A resident was administered psychotropic medications without a clear clinical indication or was given medications that could restrain their ability to function, resulting in a deficiency related to medication management.
A resident with a colostomy did not have a complete, person-centered care plan addressing all aspects of ostomy care, including monitoring for infection, leakage, and proper stoma cleaning. Staff interviews revealed gaps in knowledge and response, leading to an incident of ostomy bag leakage and stoma irritation. The care plan lacked detailed interventions, and both nursing and administrative staff acknowledged these deficiencies.
A resident with severe cognitive impairment and total care needs experienced a fall after a CNA failed to reposition the bed following incontinence care. The incident occurred during a night shift when only two CNAs were assigned to care for 50 residents, which staff and leadership acknowledged was insufficient to meet the residents' high acuity needs.
A resident with Parkinson's disease and mobility issues was prescribed trazodone, a psychotropic medication, without a documented diagnosis or clinical rationale. Despite pharmacy reviews identifying this issue and recommending a diagnosis, the resident continued to receive the medication for nearly a month without appropriate documentation. The pharmacist and DNS confirmed that the pharmacy's recommendation was not addressed in a timely manner.
A resident with significant cognitive impairment and multiple chronic conditions did not receive their scheduled morning medications on time, resulting in a medication error rate of 26.67%. The RN administered the medications over two hours late, and the delay was acknowledged by both the nurse and the DNS.
Staff did not follow enhanced barrier precautions for a resident with a urinary catheter, including failing to don gloves and gowns and neglecting hand hygiene during care. The resident's catheter bag was also placed on the floor, contrary to infection control policy. Staff interviews confirmed knowledge of the required procedures but acknowledged not following them.
A resident with cognitive impairment and a history of aggressive behaviors entered another resident's room and physically abused them, resulting in bruising. The facility failed to implement adequate monitoring or preventive measures to protect residents from such interactions, leading to a substantiated case of abuse.
Three residents did not receive ordered PT, OT, or SLP services as prescribed, including delayed evaluations, missed therapy sessions, and incomplete documentation. Staff and family confirmed therapy was not provided as ordered, with staffing shortages and missed orders contributing to the deficiency.
The facility did not consistently post accurate or complete Direct Care Staff Daily Reports, with 13 days identified where licensed nurse staff hours were either incorrect or missing information, as confirmed by the staffing coordinator.
A resident developed bilateral hand contractures and significant pain due to the facility's failure to prevent the loss of range of motion. Despite initial assessments indicating no upper extremity impairments, the resident's condition worsened over time. The care plan interventions, including the use of a carrot and an edema glove, were not consistently implemented, and the resident rarely received restorative therapy. Staff interviews confirmed the lack of a restorative plan and consistent monitoring, contributing to the resident's decline.
The facility failed to properly label and store food items, maintain a clean kitchen environment, and prevent ice machine contamination. Observations revealed improperly labeled food, unsanitary conditions, and a lack of an air gap in the ice machine's drain plumbing. The Dietary Manager and Administrator acknowledged these issues.
The facility failed to maintain a medication error rate of less than 5 percent, resulting in a 25 percent error rate. Errors included late administration of medications for a resident with chronic pain and osteoarthritis, incorrect dosage for a resident with hypertension, and incorrect timing of medications for a resident with Parkinson's disease and a psychotic disorder. These errors were acknowledged by the staff involved and confirmed by the Corporate RN.
The facility failed to provide necessary care and services to maintain personal hygiene for a resident with a fractured femur and moderately impaired cognition. The resident reported not being offered a shower since admission and had to give themselves a bed bath. Staff interviews revealed inconsistencies in following the resident's shower schedule and documenting refusals or attempts to bathe.
A facility failed to monitor and document a resident's skin conditions, leading to unaddressed bruises. Despite policies requiring weekly skin audits, the resident's bruises were not assessed or treated. Staff were unaware of specific handling instructions, and proper documentation was lacking, resulting in a deficiency in care.
The facility failed to implement fall prevention interventions and analyze falls for two residents. One resident's bed was often elevated despite care plan instructions, and another resident experienced two falls without proper incident reporting or analysis.
The facility failed to obtain physician orders and properly maintain respiratory equipment for two residents. One resident received oxygen therapy without a physician's order, and another had an oxygen concentrator set at an incorrect flow rate with a dirty filter. Staff were unclear about their responsibilities for maintaining the equipment.
The facility failed to document a clinical rationale for pharmacy recommendations for two residents. One resident with dementia and mood disorder continued on Abilify without a documented rationale, and another resident with anxiety disorder continued on Celexa and clonazepam without a documented rationale. These actions were acknowledged by the Regional RN.
A resident receiving clonazepam for anxiety disorder did not have gradual dose reductions (GDRs) attempted as required by CMS guidelines. Despite a pharmacist's recommendation and no documented behaviors indicating the need for the medication, the facility failed to attempt GDRs or provide a clinical rationale for the continued use of clonazepam.
The facility failed to follow care plans for two residents, one requiring assistance with bed mobility and another with dentures, leading to unmet needs and potential injury. Staff did not adhere to the care plans, causing pain and neglecting denture assistance.
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 Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Monitor and Maintain Medication Refrigerator Temperatures
Penalty
Summary
The facility failed to ensure proper storage and monitoring of medication refrigerator temperatures, as evidenced by review of temperature logs and staff interviews. The logs for July and August 2025 showed that temperatures were not consistently checked and recorded twice daily as required, with 15 instances where the temperature was checked only once or not at all. Additionally, there were 12 occasions when the refrigerator temperature fell below the acceptable range of 36°F to 46°F. Staff interviews confirmed that nurses were responsible for monitoring and documenting refrigerator temperatures each shift, and that out-of-range temperatures should be reported and addressed. The Environmental Services Director acknowledged that the refrigerator had been running low for several weeks and that multiple readings were below the required minimum. The Director of Nursing Services also confirmed the missed checks and out-of-range temperatures on the logs.
Failure to Provide Sufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple observations, interviews, and record reviews. On a day when the census was 53 residents, staffing lists showed a significant number of residents required two-person assistance for transfers, bathing, toileting, and dressing, as well as one-to-one feeding assistance and bariatric care. On a specific night shift, only two CNAs were present for 50 residents, which staff and family members confirmed was inadequate to meet resident acuity needs. This staffing shortage was directly linked to incidents such as a resident fall and delays in care. Throughout several days of observation, call light response times were excessively long, with some call lights going unanswered for up to 47 minutes. Residents were observed waiting for assistance with activities of daily living (ADLs), including toileting and going to bed, for extended periods. Some residents reported waiting up to two hours for help, and staff confirmed that chronic understaffing led to missed showers, delayed care, and inability to complete rounds or provide timely assistance. The lack of functioning call light monitors and staff not carrying required devices further contributed to delays in care. Specific residents experienced negative outcomes due to insufficient staffing. One resident with an ostomy reported multiple incidents where their ostomy bag burst due to delayed assistance, resulting in soiling themselves and their bed. Another resident, dependent on staff for all ADLs, reported long waits for care, especially during night shifts. Staff interviews consistently indicated that staffing was based on state minimum ratios rather than resident acuity, and that frequent call-offs and lack of agency coverage exacerbated the problem. Resident Council meeting minutes and direct resident feedback highlighted ongoing concerns with slow call light response and staff not returning after initial contact.
Misappropriation of Controlled Pain Medication Due to Improper Narcotic Counting
Penalty
Summary
A deficiency occurred when a card of oxycodone, a Schedule II controlled pain medication prescribed to a cognitively intact resident with an abdominal wall infection, was found missing during a routine narcotic count. The investigation revealed that certified medication aides (CMAs) and nurses on the night shift were not properly counting the narcotic drawer, which led to the loss of the resident's medication. The missing medication was not found, and the facility determined that misappropriation of the resident's property had occurred. Interviews confirmed that the resident was unaware of any missed doses and had not experienced any interruption in receiving needed pain medication. Staff involved in the narcotic count reported the missing card and acknowledged that the medication was likely thrown away by mistake due to improper counting procedures. The incident was substantiated as misappropriation of resident property following the facility's internal investigation.
Failure to Assess Residents for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were properly assessed for their ability to safely self-administer medications. For three residents with moderate cognitive impairment and various diagnoses, including dementia, bipolar disorder, and gastroparesis, surveyors observed medicated powders and lotions at the bedside without documentation of a self-administration assessment in the health records. In each case, there was no evidence that the residents had been evaluated for their capacity to self-administer these medications, nor were there physician orders authorizing self-administration. Staff interviews confirmed that medications were present at the bedside and that facility policy required both a physician order and an assessment for self-administration. Staff acknowledged that these requirements had not been met for the residents in question, and that medications should not have been accessible to residents without proper evaluation. The lack of assessment and unauthorized access to medications constituted the deficiency identified by surveyors.
Failure to Assess Resident for Use of Physical Restraint
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident was appropriately assessed for the use of a physical restraint. The resident, who had a history of stroke and was impaired on one side, used a motorized wheelchair with a self-releasing seatbelt. According to the facility's policy, an evaluation should be completed prior to the initiation of any device that could function as a restraint, as well as annually and upon a change of condition. However, a review of the resident's electronic medical record revealed that no assessment was completed regarding the use of the seatbelt when the resident used the motorized wheelchair. Observations over several days showed the resident moving throughout the facility in the wheelchair with the seatbelt in place. Interviews with the resident and multiple staff members indicated that the seatbelt was used for safety, but the resident could not latch it independently, though they could unlatch it. Staff confirmed that an assessment was required in such cases to determine if the seatbelt was functioning as a restraint, but were unsure if one had been completed. The Director of Nursing Services was unaware of the seatbelt use until recently and stated that assessments should be completed quarterly to ensure the seatbelt was not acting as a restraint.
Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications or the use of medications that may restrain a resident's ability to function. This deficiency indicates that residents were either prescribed psychotropic drugs without a clear clinical indication or were given medications that could limit their functional abilities, contrary to regulatory requirements.
Failure to Develop Comprehensive Ostomy Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing all aspects of ostomy care for a resident with a colostomy. The care plan in place did not include specific interventions for monitoring signs and symptoms of infection, leakage, or instructions on cleaning the stoma and peristomal skin. Documentation showed that the resident required assistance with ostomy care, and staff interviews revealed that some staff were not fully aware of the necessary procedures or were slow to respond, resulting in an incident where the ostomy bag leaked and caused irritation to the resident's stoma. Staff interviews confirmed that certified nursing assistants (CNAs) and nurses were expected to review the care plan and report any concerns related to ostomy care, but the care plan lacked detailed interventions. The resident, who was cognitively intact, expressed concerns about infection and leakage, and staff acknowledged that the care plan did not adequately address these needs. The Director of Nursing and the nurse case manager both reviewed the care plan and recognized the deficiencies in the interventions related to ostomy care.
Failure to Prevent Avoidable Fall Due to Inadequate Supervision and Staffing
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, a history of stroke, and total dependence for care experienced a fall. The resident was admitted with diagnoses including dysphagia and was identified as a high fall risk. On the night of the incident, only two CNAs were scheduled to care for 50 residents. After one CNA changed the resident's brief, the bed was not pushed back against the wall as required. Approximately 30 minutes later, the resident was found on the floor between the bed and the wall, yelling and crying to get staff attention. The resident did not sustain injuries and refused hospital evaluation. Interviews with staff and a family member confirmed that the fall resulted from the failure to reposition the bed after care and that staffing levels were insufficient to meet resident needs, especially given the high acuity of the population. Both CNAs and facility leadership acknowledged that only two CNAs were present during the shift, which was not adequate for the number of residents and their care requirements.
Failure to Address Pharmacy Recommendations for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that pharmacy recommendations regarding medication management were addressed by the physician for one resident reviewed for unnecessary medications. Specifically, a resident with Parkinson's disease and difficulty walking was prescribed trazodone, an antidepressant, without a documented diagnosis or clinical rationale for its use. Pharmacy reviews in both June and July identified the lack of an appropriate diagnosis for the new psychotropic medication and recommended that a diagnosis be provided. Despite these recommendations, the resident continued to receive trazodone for 29 days without the required documentation. Interviews with the facility's pharmacist confirmed that monthly reviews were conducted to ensure appropriate clinical diagnoses for all medications, including psychotropics, and acknowledged the absence of a diagnosis for trazodone. The Director of Nursing Services also recognized a delay in documenting clinical rationales for medications and confirmed that the pharmacy's recommendation was not followed up on in a timely manner.
Medication Error Rate Exceeds 5% Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5 percent, as required, with eight errors out of 30 opportunities, resulting in a 26.67 percent error rate. On one occasion, a resident with significant cognitive impairment and multiple diagnoses, including Parkinson's Disease, was not administered their scheduled morning medications at the prescribed time. The medications, which included carbidopa/levodopa, allopurinol, aspirin, cholecalciferol, finasteride, senna, furosemide, and metoprolol, were due at 7:00 AM but were not given until 9:06 AM. The late administration was acknowledged by the RN responsible and the Director of Nursing Services.
Failure to Implement Enhanced Barrier Precautions for Resident with Catheter
Penalty
Summary
Staff failed to implement enhanced barrier precautions (EBP) for a resident with a urinary catheter who required total assistance with activities of daily living. The facility's policy required staff to don gloves and gowns and perform hand hygiene when providing care to residents on EBP, especially during activities such as transferring and toileting. During observation, a certified nursing assistant (CNA) assisted the resident to the commode without performing hand hygiene or donning gloves and a gown. The CNA also placed the resident's catheter bag on the floor before hanging it on the commode. Another staff member entered to assist, donned gloves but not a gown, and after assisting, removed gloves and performed hand hygiene, while the first CNA left the room without performing hand hygiene. Interviews with both staff members confirmed their awareness of the EBP requirements and acknowledged their failure to follow proper infection control procedures, including the use of personal protective equipment and hand hygiene. The director of nursing services also confirmed that all residents on EBP require staff to adhere to infection control practices and that catheter bags should not be placed on the floor. These lapses in protocol placed residents at risk for transmission of infection.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
A resident with vascular dementia and peripheral vascular disease, who refused cognitive assessment, was subjected to abuse by another resident diagnosed with a femur fracture and Alzheimer's disease. The second resident, who had severe cognitive impairment and a history of physical and verbal behaviors, wandered into the first resident's room, demanded the resident leave their bed, and pinched the resident's wrist, resulting in two small bruises. The incident was substantiated as abuse by facility staff, and the affected resident expressed distress and requested to be kept away from the aggressor. Staff interviews confirmed that the aggressive resident was known to exhibit physical aggression and had previously scratched and hit staff members. At the time of the incident, there were no specific interventions in place, such as one-on-one supervision, to prevent the aggressive resident from interacting with other residents. Staff responded to the incident after it occurred, but prior to the event, monitoring and preventive measures were insufficient to protect the resident from abuse.
Failure to Provide Ordered Rehabilitative Therapy Services
Penalty
Summary
The facility failed to provide specialized rehabilitative services, including physical, occupational, and speech therapy, as ordered for three residents who required these services. One resident with a history of stroke, hemiparesis, and dysphagia was admitted with orders for SLP and OT evaluations and treatment. However, the SLP evaluation was delayed by 16 days and the OT evaluation by 19 days after admission. Furthermore, the resident did not receive the prescribed frequency of SLP and OT treatments for two out of four weeks, with staff confirming the lack of adequate therapy staffing as the cause. Another resident with chronic pain syndrome and bilateral hip arthritis was readmitted from the hospital with orders for PT and OT evaluation and management. The electronic health record showed no evidence that these evaluations were completed, and the resident confirmed not receiving the therapy services as ordered. Staff acknowledged the orders were missed but could not provide a reason for the omission. A third resident with hemiplegia and aphasia had orders for PT, OT, and SLP evaluations and treatments. The therapy schedules indicated multiple missed sessions across all three disciplines, with staff citing therapist absences and lack of documentation for the missed sessions. Family members and staff confirmed the resident did not receive therapy as frequently as ordered, and the administrator acknowledged the missed sessions.
Inaccurate and Incomplete Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure that the Direct Care Staff Daily Report (DCSDR) postings were accurate and complete for 13 out of 77 days reviewed. A review of the DCSDRs from 6/1/25 through 8/18/25 revealed that on specific dates, the postings either contained inaccurate licensed nurse staff hours or had missing/incomplete information. This was confirmed during an interview with the Human Resources/Payroll/Staffing Coordinator, who verified the inaccuracies and incomplete postings on the identified days.
Failure to Prevent Loss of Range of Motion and Development of Contractures
Penalty
Summary
The facility failed to prevent the loss of range of motion and the development of contractures for a resident, resulting in bilateral hand contractures and significant pain. The resident was admitted with spinal stenosis and initially had no upper extremity impairments. However, over time, the resident developed weakness and impairments in both arms, which were documented in various medical notes and evaluations. Despite these observations, there was no evidence in the resident's clinical record indicating that the impairments were comprehensively assessed or that ongoing monitoring and exercises were provided to maintain or improve the resident's range of motion or prevent further declines. The resident's care plan included the use of a carrot in the right hand and an edema glove on the left hand, but these interventions were not consistently implemented. Observations and interviews revealed that the resident rarely received restorative therapy, and staff were often unaware of the care plan details or failed to provide the necessary interventions. The resident and a witness reported that the resident experienced significant pain in her/his hands and that the prescribed interventions were not being offered regularly. Staff interviews confirmed the lack of a restorative plan and the absence of consistent monitoring and assessment of the resident's contractures. Several staff members acknowledged that the resident's contractures had worsened and that the resident frequently complained of pain. The facility's failure to implement and monitor the care plan interventions, as well as the lack of a restorative program, contributed to the resident's decline in functional status and increased pain.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of food items, maintain a clean and sanitary environment for food preparation, and prevent potential contamination of the ice machine. Observations in the kitchen revealed partially-consumed containers of various condiments and sandwiches that were not labeled or dated correctly, making it impossible to determine their freshness. Additionally, a pork loin was observed thawing above chicken, posing a risk of cross-contamination. The Dietary Manager acknowledged these issues and stated that the labeling should include the year and that meats should be positioned to thaw at the bottom of the refrigerator to prevent dripping on other items. Further observations identified unsanitary conditions in the kitchen, including dust and grit on supply shelves, accumulated fuzz and dust on ceiling support beams and pipes, and a weathered, oxidized dome covering a test tray. The ice machine in the 200 hall was found to drain directly into the floor plumbing without an air gap, and the ice scoop holster contained standing water with black dust particles. The area around the ice machine was also observed to be unsanitary, with used PPE, black grime, and debris in a puddle of water. The Administrator acknowledged these issues and understood the need for an air gap in the ice machine's drain plumbing to protect against potential backflow from the sewer line.
Medication Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5 percent, resulting in a 25 percent error rate. This was observed through multiple instances of late or incorrect medication administration. For Resident 6, who has chronic pain and osteoarthritis, gabapentin and Voltaren gel were administered significantly later than the prescribed times on two separate occasions. Staff 12 and Staff 13 both acknowledged the late administration of these medications. Additionally, Resident 32, who has hypertension, received only one spray of Ipratropium Bromide nasal solution instead of the prescribed two sprays. Staff 13 acknowledged this error upon review of the physician order. Lastly, Resident 14, diagnosed with Parkinson's disease and a psychotic disorder, received carbidopa levodopa and Seroquel at incorrect times, with the evening dose of Seroquel being administered in the afternoon. Staff 16 acknowledged the short duration between doses and the incorrect timing of the evening medication. These medication errors were confirmed by Staff 2 (Corporate RN) who acknowledged the identified errors for all three residents. The errors included late administration of medications, incorrect dosage, and incorrect timing of medication administration. These deficiencies placed the residents at risk for adverse medication side effects and pain.
Failure to Maintain Personal Hygiene for Resident
Penalty
Summary
The facility failed to provide necessary care and services to maintain personal hygiene for a resident admitted with a fractured femur and moderately impaired cognition. The resident reported not being offered a shower since admission and had to give themselves a bed bath. Observations confirmed the lack of proper bathing supplies at the resident's bedside. The resident's care plan indicated they needed extensive assistance for bathing, with scheduled showers every Monday and Thursday evening. However, records showed no documentation of showers, bed baths, or attempts to bathe the resident on specific dates. Interviews with staff revealed inconsistencies in following the resident's shower schedule and documenting refusals or attempts to bathe. CNAs and LPNs acknowledged the expectation to document all bathing activities and refusals, but there was no record of such documentation for the resident in question. The Regional RN confirmed the expectation for the resident to be bathed on scheduled days and as requested, but this was not adhered to, leading to the deficiency.
Failure to Monitor and Document Resident's Skin Conditions
Penalty
Summary
The facility failed to monitor and document the skin conditions of a resident, leading to unaddressed bruises and potential unmet care needs. The resident, admitted in April 2024 with multiple diagnoses including acute respiratory failure with hypoxia, had multiple bruises and dry, discolored skin on both upper extremities. Despite the facility's policy requiring weekly full-body skin audits and documentation of any skin impairments, the resident's bruises were not assessed, treated, or monitored as per the policy. The resident's clinical records did not indicate any monitoring or treatment of the bruises, and the Treatment Administration Record (TAR) did not reflect the presence of these bruises. Observations and interviews revealed that the resident had dark purple bruises on both hands and forearms, which were not being monitored. Staff members, including CNAs and nurses, were either unaware of the specific handling instructions for the resident's skin or had not documented the bruises properly. The RN and LPN confirmed that the bruises should have been monitored and documented, and an incident report should have been completed. The lack of proper assessment and monitoring of the resident's bruises was a clear deviation from the facility's policy, leading to a deficiency in care.
Failure to Implement Fall Prevention and Analyze Falls
Penalty
Summary
The facility failed to implement fall prevention interventions and evaluate and analyze resident falls for two residents. Resident 23, admitted with spinal stenosis, was identified as a high fall risk with a history of self-transferring and falling. Despite care plan instructions to keep the bed in the lowest position and use a bedside fall mat, observations revealed the bed was often elevated to waist height, and the fall mat was not in place. Staff acknowledged the care plan was not being followed, placing the resident at risk for injury. Resident 32, admitted with rhabdomyolysis and severe cognitive impairment, experienced two falls on the same day. The facility failed to complete Fall Incident Reports for both falls, and there was no evidence of risk identification, evaluation, or root cause analysis. Staff confirmed the lack of documentation and investigation, which is required for every fall. This failure to follow protocol and implement necessary interventions placed the resident at risk for further injury.
Failure to Obtain Physician Orders and Maintain Respiratory Equipment
Penalty
Summary
The facility failed to obtain physician orders, ensure respiratory equipment was properly maintained, and administer oxygen as ordered for two residents. Resident 32 was observed receiving oxygen therapy without a physician's order or a care plan directing staff on how to monitor or administer the oxygen. Staff confirmed the absence of a physician order and care plan for Resident 32's oxygen therapy, despite the resident wearing oxygen daily as per the staff's observations and statements. Resident 28, who was admitted with acute respiratory failure with hypoxia, was observed receiving oxygen at an incorrect flow rate and with a concentrator filter covered in a thick layer of dust. Staff were unclear about their responsibilities regarding the maintenance and cleaning of the oxygen concentrator filters. The resident's oxygen concentrator was set to deliver 2.5 liters per minute instead of the ordered 2 liters, and the filter had not been cleaned as required. Staff confirmed the discrepancies and the lack of clarity on who was responsible for cleaning the filters.
Failure to Document Clinical Rationale for Pharmacy Recommendations
Penalty
Summary
The facility failed to document a clinical rationale for pharmacy recommendations for two residents reviewed for unnecessary medications. Resident 24, who was admitted with diagnoses including dementia and mood disorder, had been receiving Abilify since May 2023. The pharmacist recommended a gradual dose reduction (GDR) as per CMS guidelines, but the physician signed off on continuing the medication without providing a clinical rationale. This omission was acknowledged by the Regional RN on May 16, 2024. Similarly, Resident 3, admitted with an anxiety disorder, had been receiving Celexa and clonazepam. The pharmacist also recommended a GDR for these medications, but again, the physician signed off on continuing the medications without providing a clinical rationale. This was also acknowledged by the Regional RN on May 16, 2024. These actions placed the residents at risk for unnecessary medication administration.
Failure to Attempt Gradual Dose Reductions for Psychotropic Medication
Penalty
Summary
The facility failed to attempt gradual dose reductions (GDRs) for a resident who had been receiving clonazepam 0.5 mg twice daily for anxiety disorder since their admission in 2012. According to the Centers for Medicare and Medicaid Services (CMS) guidelines, GDRs should be attempted in two separate quarters during the first year and annually thereafter unless clinically contraindicated. Despite these guidelines, the resident's clinical record revealed no dose changes or GDRs were completed, and there was no clinical rationale documented to support the continued use of clonazepam. The pharmacist had recommended assessing the resident for GDR, but this recommendation was not followed. Additionally, behavior monitoring records from a one-month period showed no documented behaviors for the resident, further questioning the necessity of the continued medication. The Corporate RN acknowledged the lack of documented behaviors and the failure to attempt a GDR or provide a clinical rationale for the continued use of clonazepam.
Failure to Implement Care Plans for Two Residents
Penalty
Summary
The facility failed to implement the plan of care for two residents, leading to unmet needs and potential injury. Resident 139, who was admitted with bilateral femur fractures and had a care plan requiring extensive assistance by two staff members for bed mobility, experienced an incident where a CNA independently provided bed mobility and ADL care, causing pain. This incident was reported and investigated, revealing that the CNA did not follow the care plan, and the facility's administrator acknowledged awareness of the incident and the expectation for staff to follow care plans. Resident 32, admitted with severe cognitive impairment and requiring assistance with dentures, was observed multiple times without dentures in their mouth. Despite the care plan indicating the need for assistance with dentures, staff failed to ensure the resident wore them. One CNA found the dentures in a soaking cup, and another CNA, unfamiliar with the resident, did not assist with dentures based on incorrect information from other staff. The LPN and Regional RN confirmed the expectation for staff to follow the care plan regarding dentures.
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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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