Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Glisan Post Acute during CMS and state inspections, most recent first.
Unlocked medication and treatment carts were left unattended in multiple areas of the facility, with medications and treatment supplies accessible to others. An LPN, a CMA, and an RN each acknowledged the carts were unlocked, and the DNS stated carts were expected to be locked when unattended.
Improper Food Storage and Labeling in Unit Refrigerator and Freezer: The facility failed to properly store food and maintain sanitary conditions in the unit refrigerator and freezer. Multiple food items were found unlabeled and undated, and opened food boxes were stored on the freezer floor. The Dietary Mgr acknowledged the issues and stated food items should be labeled, dated, and stored off the floor.
Improper PPE Use and Linen Separation Failures: Staff were observed removing face shields by touching the front, storing and reusing them in inappropriate locations, and entering TBP rooms without the required PPE, including a face shield. In addition, clean linens were stored in the same shower room as trash and soiled linen barrels, with towels and washcloths also left in the room, despite policy requiring clean and soiled linens to remain separated.
Failure to Assess Residents for Self-Administration of Medications: The facility allowed multiple cognitively intact residents to keep OTC and other medications at the bedside without a current self-administration assessment or MAR indication. A resident with metabolic encephalopathy had several OTC products in the room, another resident had vitamins, artificial tears, and throat spray in the room, and a third resident had nasal saline solution at the bedside. Staff, including CNAs, CMA, LPNs, the RCM, and the DNS, confirmed the medications were present and stated residents should not have medications unless a self-administration assessment was on file.
Homelike Environment Not Maintained Due to Constant Door Alarm Noise: A cognitively intact resident with insomnia reported that a backdoor alarm outside the room rang constantly, especially at night, and prevented sleep. Staff observed the alarm sounding repeatedly, including inside the resident’s room with the door shut, and multiple CNAs and an LPN confirmed the noise was frequent, loud, and bothersome to residents. The Administrator stated she was unaware of the complaint and did not view the alarm sounding throughout the day and night as consistent with a homelike environment.
A resident with acquired absence of larynx and a tracheostomy did not receive completed BIMS and PHQ-2 to 9 assessments. The resident was nonverbal but could communicate in writing, and staff did not attempt the BIMS using the resident’s preferred communication method or reattempt the mood interview after an initial interruption. The DNS stated these interviews were expected to be attempted with all residents using their preferred method of communication.
Failure to provide grooming assistance for two residents led to poor hygiene and loss of dignity. One resident with quadriplegia and diabetes had long fingernails with debris under them despite a physician order for weekly nail checks and trimming by an LPN, and staff acknowledged the nails had not been trimmed since admission. Another resident with schizophrenia required substantial-to-maximal help with hygiene and had long facial hair on the chin, but staff generally offered facial hair grooming only during showers or if requested, and the resident stated staff had not offered assistance even though it was wanted.
Failure to Provide Person-Centered Activities: A resident with quadriplegia and DM2 had a care plan calling for individualized, in-room activities such as Bible study, music, reading materials, and one-to-one visits, but records showed no documented activity engagement over a 30-day period. Observations found the resident in bed watching TV without activity materials in the room, and staff reported no observed in-room or individualized activity support from the activity dept.
Failure to assess independent tracheostomy care and complete respiratory care plan: A cognitively intact, nonverbal resident with a laryngectomy/tracheostomy was documented as doing trach care independently, but staff had not observed a full return demo and did not know the tube size/type. During observation, the resident performed care without hand hygiene or gloves, handled supplies on stained linens, and struggled to re-thread the trach ties. The care plan and orders did not include the laryngectomy tube size/type or a comprehensive assessment of the resident’s ability to perform the care.
Failure to obtain timely dental services for a resident with malnutrition and intact cognition. The resident had all teeth extracted, repeatedly asked staff about getting dentures, and reported trouble chewing and eating. Staff stated no denture appointment had been scheduled, the denture process had not started, and the DNS acknowledged dental services were not provided timely.
Surveyors found that kitchen equipment and food preparation areas were not maintained in a clean and sanitary manner, with visible dust, debris, grease, and food particles on multiple surfaces and storage areas. Staff interviews revealed a lack of routine cleaning protocols and documentation, and both the Dietary Manager and Administrator acknowledged the need for significant improvement in kitchen cleanliness.
A resident with chronic pain did not receive scheduled doses of oxycodone due to the facility's failure to reorder the medication in a timely manner. The pharmacy had notified the facility of the need for new orders, but delays in obtaining these orders led to missed doses, impacting the resident's pain management.
The facility failed to maintain sanitary conditions in dining services, with moldy ice scoop storage and unclean ice machine equipment. In the kitchen, opened and undated food items, expired products, and improper glove use during meal preparation were observed, violating food handling protocols.
The facility failed to ensure a clean and homelike environment in a shower room on the TCU, with issues such as black substance on floorboard edging, cracked flooring, and a dirty fan. Additionally, two residents had wheelchair armrests in disrepair, with torn coverings and peeling tape, making them uncleanable. Staff confirmed these deficiencies.
A resident with a fracture and schizophrenia reported missing clothing after staff took it to the laundry. Despite informing several staff members, no grievance process was initiated. The Housekeeping Supervisor was unaware, and a CNA did not report the issue. The DON stated that staff should check the inventory and start a grievance if items were not found, but this was not done.
A resident with hemiparesis and hemiplegia, who was moderately cognitively impaired and had difficulty hearing, did not receive appropriate communication support in their preferred language, Vietnamese. The facility failed to provide necessary communication aids, such as cue cards, and the translation service was non-functional. Staff interviews revealed a lack of awareness and use of these aids, and the resident's care plan was missing interventions for their hearing impairment.
A resident with neuromuscular dysfunction of the bladder did not receive adequate bathing assistance as per their care plan. The resident was scheduled for showers twice a week but was not consistently offered them, and refusals were not properly documented or reoffered. Staff interviews revealed inconsistencies in following the facility's protocol for reoffering showers, leading to unmet hygiene needs.
Two residents in an LTC facility did not receive person-centered activities, leading to a deficiency. One resident, with cognitive impairments, was not engaged in any activities despite expressing interest in reading and outings. Another resident, with hemiparesis, faced language barriers and lacked suitable materials, preventing participation in preferred activities. Staffing changes and lack of awareness of residents' preferences contributed to the deficiency.
A resident with chronic pain and opioid dependency was improperly administered oxycodone, as the facility failed to follow physician orders. The resident received 10 mg of oxycodone for moderate pain and 5 mg for severe pain, contrary to prescribed parameters, risking ongoing pain or over-sedation.
A resident at risk for pressure ulcers was not provided with a suitable cushion for their wheelchair, leading to skin irritation and breakdown. Despite repeated requests and staff acknowledgment of the need for a cushion, the resident continued to sit on a folded towel, highlighting a failure in implementing necessary interventions.
Two residents in a LTC facility did not receive appropriate care to prevent further decreases in range of motion. One resident with hemiparesis and hemiplegia lacked consistent application of a care plan involving a palm guard and therapy carrot. Another resident with dementia and left-sided weakness had no evidence of assessment or support for contracture management. Staff interviews revealed confusion and lack of coordination in implementing restorative programs.
A resident with PTSD and a history of trauma was admitted to a facility, but their care plan for PTSD was delayed by 38 days, leaving them without appropriate interventions. The resident experienced anxiety and night terrors, with known triggers not addressed in the care plan. Staff interviews revealed a lack of awareness and communication about the resident's needs, leading to inadequate trauma-informed care.
A resident with PTSD and stimulant abuse was not provided necessary behavioral health services, including counseling or peer support, in a LTC facility. The resident's care plans were not person-centered, and staff were unaware of the resident's anxiety attack and lack of individualized care. The resident expressed dissatisfaction with the facility's support for their PTSD and anxiety.
A resident with specific food preferences and dislikes was repeatedly served meals containing items they disliked, such as green beans and gravy, despite these preferences being documented. The dietary staff, including the cook and Dietary Director, acknowledged the resident's preferences but failed to adhere to them, leading to the resident refusing meals. The facility administrator acknowledged the findings without providing further information.
A resident with cognitive impairment sustained a second-degree burn after being served excessively hot coffee, which was taken out of the kitchen before cooling to a safe temperature. The incident occurred when an agency CNA found the resident had spilled the hot coffee on their lap, leading to a burn on the thigh. Dietary staff confirmed the coffee was brewed too hot, and the facility administrator acknowledged the premature removal of the coffee cart.
Unlocked Medication and Treatment Carts Left Unattended
Penalty
Summary
The facility failed to ensure medications and biologicals were secured for 1 of 4 medication carts and 1 of 3 treatment carts reviewed for safe medication storage. The facility’s undated Storage of Medication Policy stated only licensed nurses, pharmacy staff, and other authorized personnel were allowed access to medication carts, and that medication rooms, cabinets, and supplies should remain locked when not in use or attended by authorized persons. On 3/11/26, an unlocked and unattended treatment cart was observed in the east hall across from the nurse’s station with two boxes of enoxaparin for Resident 15 on top of the cart. CNA staff were in the area, and a resident in a wheelchair was observed near the cart, with the cart contents accessible. Staff 37, an LPN, acknowledged the cart was unlocked and unattended and stated it should be locked when unattended and medications should not be stored on top of the cart. On 3/12/26, an unlocked and unattended medication cart was observed on the south side of the facility with the day and evening shift medications for residents in Rooms 131 through 138 accessible; Staff 16, a CMA, acknowledged the cart was unlocked and unattended. On 3/11/26, another treatment cart in the ICF hallway near the nurse’s station was observed unlocked and unattended with residents’ insulin, creams, and other treatment supplies inside; Staff 9, an RN, stated he had left it unlocked and unattended. The DNS stated it was her expectation that medication and treatment carts be locked when unattended.
Improper Food Storage and Labeling in Unit Refrigerator and Freezer
Penalty
Summary
The facility failed to properly store food and failed to maintain sanitary conditions for 1 of 1 unit refrigerators and 1 of 1 unit freezers. Observation of the unit refrigerator and freezer revealed multiple food items that were unlabeled and undated, including two plastic bags of hot dogs, a large container of sliced pepperonis, a small container of lemon wedges, a large container of shredded cheese, a plastic container of pulled pork, and two plastic bags of premade egg patties. Other items in the refrigerator were a container of corn dated 3/2, a container of chicken fried steak dated 2/17, and a container of spaghetti sauce dated 12/3. In the freezer, an opened box of ice cream bars and an opened box of bags of corn were stored on the floor. Staff 4, the Dietary Manager, acknowledged the unlabeled and undated food items and the food stored on the floor of the freezer and stated food items should be labeled, dated and stored off the floor.
Improper PPE Use and Linen Separation Failures
Penalty
Summary
The facility failed to ensure appropriate use and disposal of PPE in accordance with CDC guidance and its own Droplet/Contact Precautions sign for residents in rooms identified as Transmission Based Precautions for COVID-19. Staff were observed removing face shields by touching the front of the shield and placing them behind the hand rails of the wall near the room, then later retrieving and reusing the same face shield from that location. Staff were also observed entering the TBP rooms without a face shield, and one CNA was observed entering a TBP room without donning PPE to deliver water and briefs. The Infection Preventionist stated staff were expected to follow the TBP signage, don PPE including a face shield before entering, remove all PPE before exiting, and not handle the face shield by the front or store it on PPE carts or behind hand rails. The DNS stated staff were expected to don the required PPE before crossing through the doorway of the room and that appropriate PPE included a gown, gloves, respirator, and face shield. The facility also failed to keep clean and soiled linens separated. In the [NAME] hall shower room, clean linens were observed placed on a shelf inside the room while a covered trash barrel and a covered soiled linen barrel were also present in the same room. Folded wash cloths and bath towels were observed on top of a shower chair in the shower room, and staff were observed placing a bag into the soiled linen barrel there. Staff stated the barrels were stored in the shower room because of inadequate space, and that clean linens were not supposed to be stored there because a clean linen storage room was directly across from the shower room. The facility’s Laundry and Linen Policy required soiled and clean linen to be separated at all times and to treat soiled linen as potentially infectious. The Infection Preventionist acknowledged clean linens and soiled linens were expected to be kept and stored separately due to the risk of cross contamination, and the DNS stated clean linens were expected to be stored separately from soiled linens to prevent cross contamination.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure residents were assessed before being allowed to self-administer medications. The facility’s Self Administration of Medication policy stated that no medications are to be stored at bedside or self-administered until an evaluation is complete, a physician order is obtained for the specific medications the resident may self-administer, medications are identified on the MAR as self-administered, and the resident is reevaluated annually and with significant change in condition. Resident 60 was admitted with a diagnosis of metabolic encephalopathy, and the quarterly MDS showed a BIMS score of 13, indicating cognitive intactness. Observations found Calcium Magnesium, Benadryl, Calamine lotion, multivitamins, and Cetirizine Hydrochloride on the nightstand and bedside table. The clinical record contained no self-administration assessment for those medications, and the MAR for 3/2026 did not indicate any medications were to be self-administered. Staff stated they were unaware of residents being authorized to self-administer medications, and the LPN and RCM both confirmed the medications were in the room and that a self-administration assessment was needed. Resident 13 was admitted with calculus of kidney and had a BIMS score of 15. Observations found Vitamin B12, Caltrate bone vitamins, artificial tears, and phenol throat spray in the room, while the record only showed a self-administration assessment from 10/11/24 for Vitamin B Complex and no assessment within the last 12 months for the other items. Resident 13 stated the throat spray was being used for throat relief, and staff confirmed the medications were in the room and that the resident was not authorized to self-administer them. Resident 10 was admitted with cellulitis of the right lower limb and had a BIMS score of 15. A bottle of nasal saline solution was observed on the bedside table, the resident stated staff had given it for independent use, and the record contained no self-administration assessment for it. Staff confirmed the saline solution was at the bedside and that a self-administration assessment was needed.
Homelike Environment Not Maintained Due to Constant Door Alarm Noise
Penalty
Summary
The facility failed to ensure a comfortable and homelike environment for one resident who was cognitively intact and had a diagnosis of insomnia. The resident was readmitted to the facility in 3/2023, and the 2/5/26 quarterly MDS indicated the resident was cognitively intact. The facility’s Homelike Environment Policy stated staff and management should maximize characteristics of the facility that reflect a personalized, homelike setting, including comfortable sound levels. On 3/10/26 and 3/11/26, the backdoor alarm located just outside the resident’s room was repeatedly observed sounding loudly, including while the resident was in bed with the room door shut. The resident stated the alarm rang constantly, especially at night, and prevented sleep. The resident also stated the noise was very intrusive and had been complained about to multiple people. Several staff members confirmed the alarm sounded frequently, including during the night, and stated it was bothersome to residents and loudest in the resident’s room. The Administrator stated she was unaware of the complaint and did not consider the alarm sounding throughout the day and night to constitute a homelike environment.
Incomplete Cognitive and Mood Assessments for a Nonverbal Resident
Penalty
Summary
The facility failed to complete comprehensive assessments in the areas of cognition and mood for 1 of 1 sampled resident reviewed for respiratory care. The resident was admitted in 2/2026 with diagnoses including acquired absence of larynx and encounter for attention to tracheostomy. The admission MDS dated 2/26/26 indicated the resident had no speech but was able to communicate to and understand others without difficulty. The MDS also indicated the BIMS and Resident Mood Interview (PHQ-2 to 9) were not completed because the resident was rarely/never understood. On 3/9/26, the resident was observed in the room and was nonverbal but able to appropriately communicate with the state surveyor through written communication. On 3/11/26, the Social Services Director stated she was responsible for completing the BIMS and PHQ-2 to 9 interviews and did not attempt the BIMS because the resident was unable to verbally communicate. She also stated she entered the room once to attempt the mood interview but was unable to start it because the resident was busy with nursing staff, and she did not reattempt the interview. The DNS stated she expected the BIMS and PHQ-2 to 9 interviews to be attempted with all residents using the residents' preferred method of communication and reattempted if initially refused.
Failure to Provide Nail and Facial Hair Grooming Assistance
Penalty
Summary
The facility failed to provide necessary care and assistance to maintain good grooming and hygiene for 2 residents reviewed for ADLs. One resident was admitted with diagnoses including quadriplegia and type 2 diabetes and required maximum assistance with all ADLs. A physician order directed a licensed nurse to check the resident’s fingernails and toenails weekly on bath days and trim as needed, and the TAR reflected that order. On observation, the resident’s fingernails were long and had thick, skin-colored debris beneath them, and the resident stated the nails needed to be cut and hurt because they were so long. Staff stated the resident’s nails were long, that a licensed nurse would have to trim them because the resident was diabetic, and that the resident had previously been treated for a fungal infection on the fingernails and toenails. The Director of Nursing acknowledged the resident’s fingernails had not been trimmed since admission. The second resident was admitted with schizophrenia and, according to the MDS, could make self understood and understand others without difficulty but required substantial-to-maximal assistance with personal hygiene tasks and did not reject care. The resident’s care plans indicated the resident preferred bathing on Wednesday and Sunday evenings, required assistance from one person, and needed set-up assistance and encouragement with hygiene. The personal hygiene task log showed the resident refused hygiene care on 2 occasions but was otherwise cooperative. During observation, the resident had approximately one-inch facial hair on both sides of the chin and stated the hair bothered the resident and that staff had not offered to trim it, though the resident would accept the offer. Later observations again showed long white facial hair on either side of the resident’s chin, and the resident stated staff had not offered to remove it. Multiple CNAs and an RN stated facial hair grooming was offered during scheduled showers or only if requested, and several staff said they had not offered the resident facial hair grooming. The LPN resident care manager stated facial hair grooming was provided per resident request and acknowledged she had not considered that residents with limited access to a mirror or those unable to request assistance might still want help with facial hair grooming. She also stated she was unaware of the resident’s preference for facial hair.
Failure to Provide Person-Centered Activities
Penalty
Summary
The facility failed to provide an ongoing person-centered activities program for one resident who was admitted with diagnoses including quadriplegia and Type 2 diabetes. The resident’s activity care plan documented preferences for Bible study, cell phone use, music, one-on-one visits, individual activities rather than group activities, television, and visits with friends and family, and the admission MDS indicated the resident was cognitively intact. The resident required total assistance because of quadriplegia and was unable to independently engage in activities without staff help. A review of the resident’s activity task records for a 30-day period showed no documented in-room activities, no documented one-to-one activity visits, and no documented participation in facility activity programming. During observations, the resident remained in bed in the room with the television on, and no books, magazines, newspapers, puzzles, music devices, or other activity materials identified in the care plan were present. Staff stated they had not observed activity staff offer in-room activities or one-to-one engagement, and the Activity Director acknowledged she had spoken with the resident informally but did not document those interactions and had not provided in-room activity materials or individualized activities.
Failure to Assess Independent Tracheostomy Care and Complete Respiratory Care Plan
Penalty
Summary
The facility failed to ensure a resident with an acquired absence of larynx and an encounter for attention to tracheostomy was comprehensively assessed to independently perform tracheostomy care, and failed to develop a person-centered care plan for respiratory care. The resident was admitted cognitively intact, nonverbal, and able to communicate in writing. The respiratory care plan directed respiratory treatments and tracheostomy care each shift and as needed, and physician orders later directed daily cleaning of the laryngectomy insertion site, daily stoma care, tracheostomy tie changes on Mondays and Thursdays, and removal and cleaning of the laryngectomy tube as needed. The record showed the resident was determined appropriate to complete oral and laryngectomy tube suctioning independently, and the treatment administration record documented site care and tie changes, but there was no evidence in the clinical record of the type or size of the laryngectomy tube. Staff members stated the resident had been completing tracheostomy care independently, but several also stated they had never observed the resident perform the full procedure or a return demonstration. Staff also stated they did not know the size or type of the laryngectomy tube, and multiple staff confirmed this information was not included in the physician orders or care plan. During observation, the resident attempted to perform tracheostomy care independently without hand hygiene or gloves, handled the laryngectomy tube and supplies on stained linens and a stained washcloth, and was unable to re-thread the tracheostomy ties without assistance. The resident inserted a new laryngectomy tube after wiping the stoma with a wipe from a partially opened package, then struggled for several minutes to secure the ties before finally completing the task. Staff stated the resident had not been comprehensively assessed to perform tracheostomy care independently, and the director of nursing confirmed the resident should have been assessed and that the laryngectomy tube size and type should have been included in the care plan.
Failure to Obtain Timely Dental Services
Penalty
Summary
The facility failed to obtain dental services for 1 of 2 sampled residents reviewed for dental care. Resident 16 was admitted with diagnoses including malnutrition, had a BIMS score of 15 indicating cognitive intactness, and the care plan noted staff were to coordinate and make arrangements for dental care services and that the resident had his/her own teeth. A dental treatment summary later indicated that all of Resident 16's teeth were extracted. Resident 16 stated that all teeth had been extracted about eight months earlier, that he/she had repeatedly asked staff about getting dentures without receiving a response, and that he/she was having trouble chewing and eating. Staff interviews showed the resident's mouth had been swollen after the extractions, no appointment had been scheduled to begin the denture process, and the in-house dentist had also not scheduled an appointment. Staff stated the denture process typically began eight weeks after extractions, but Resident 16 had not started that process. The DNS stated dental services were not provided timely for Resident 16.
Failure to Maintain Sanitary Kitchen Conditions
Penalty
Summary
Surveyors observed that the facility failed to maintain kitchen equipment and food preparation areas in a clean and sanitary condition, as required by professional standards and the facility's own policy. During a kitchen inspection, numerous sanitation issues were identified, including a fan blowing into the food prep area with visible dust and debris, ovens with hard coatings and burnt substances, a grill with grease and food build-up, and floors and walls with various spills, sticky substances, and black debris. Bulk food bins and their surrounding areas were found with food particles and spills, and clean dishware storage areas had food particles in contact with clean items. Cooking utensils were stored in drawers with sticky spills, and the majority of the kitchen flooring and baseboards had significant debris and residue. Interviews with dietary staff revealed a lack of awareness regarding routine cleaning protocols and documentation requirements. Staff reported that each person was responsible for cleaning their own area, but there was no formal system or documentation in place to ensure compliance. The Dietary Manager, who was new to the position, confirmed that the kitchen did not meet cleanliness expectations, and the Administrator acknowledged the need for significant improvement in kitchen sanitation.
Failure to Timely Reorder Medication Results in Missed Doses
Penalty
Summary
The facility failed to reorder a medication in a timely manner, resulting in missed doses for a resident with chronic pain. The resident was admitted in May 2022 and had a physician order for 5 mg of oxycodone to be administered three times a day for pain management. However, the resident did not receive the scheduled evening dose on December 4, 2024, and the morning dose on December 5, 2024, due to the lack of a refill and the need for new physician orders. The pharmacy had informed the facility on December 2, 2024, that no refill was available, and new orders were required. Despite this, the new physician orders were not placed until December 4, 2024, at 9:00 PM, after the resident's supply was depleted. Staff confirmed that the medication was requested to be refilled when ten doses remained, but the delay in obtaining new orders led to the missed doses. The resident reported the missed doses and was informed that the medication was unavailable due to the need for new orders.
Sanitation and Food Handling Deficiencies
Penalty
Summary
The facility failed to maintain sanitary conditions in its dining services, specifically concerning the handling and storage of ice. Staff 21, a CNA, was observed using an ice scoop stored in a white mesh bag with visible mold growth to serve ice to residents. The ice scoop holder mounted on the wall near the ice machine was also found to be unclean, with black, slimy debris. Staff 14, the Housekeeping Supervisor, confirmed the container was not clean and was unsure of the cleaning frequency. The Administrator acknowledged the expectation for clean ice scoop containers. In the kitchen, the facility did not adhere to its food preparation and service policy. Several opened and undated food items were found in the dry storage area, including French onions, vinegar, and various seasoning mixes. Additionally, expired items such as horseradish and mayonnaise were present, along with items whose expiration dates could not be determined. In the walk-in freezer, a large chunk of ice was positioned above an open box of corn, and freezer-burned asparagus and an open bag of bratwurst were observed. Staff 15, the Dietary Director, acknowledged that these items should be discarded. During the lunch tray line service, Staff 25, a cook, failed to change gloves between tasks, despite handling various surfaces and food items. The cook was observed opening drawers and the freezer door, retrieving food, and plating meal trays without changing gloves. When questioned, Staff 25 incorrectly stated that gloves were changed after touching doors. Staff 15 later confirmed that staff were expected to change gloves between tasks, indicating a lapse in adherence to the facility's food handling protocols.
Facility Fails to Maintain Clean Environment and Equipment
Penalty
Summary
The facility failed to maintain a clean and homelike environment in one of the three shower rooms on the Transitional Care Unit (TCU). Observations made over several days revealed that the shower had a black substance along the metal floorboard edging, deep cracks with black substance in the flooring, and a dirty overhead fan that emitted a loud grinding noise. The Housekeeping Supervisor confirmed that the shower's floorboard was rusted and uncleanable, the flooring was cracked, and the fan was dirty, acknowledging that the shower was not clean or homelike. Additionally, the facility did not ensure that residents' personal equipment was in good repair. Two residents were observed with wheelchair armrests in disrepair; one had a torn covering with exposed foam, and the other had black tape peeling back, making the surfaces uncleanable. The Maintenance Assistant confirmed that these issues had been reported to the maintenance department, and the Director of Nursing Services acknowledged the poor condition of the wheelchair armrests.
Failure to Initiate Grievance Process for Missing Personal Property
Penalty
Summary
The facility failed to initiate a grievance process for a resident who reported missing personal property. The resident, admitted with a displaced intertrochanteric fracture of the left femur and schizophrenia, stated that after arrival, staff took their clothes to the laundry and did not return them. Despite informing several staff members about the missing clothing, no grievance process was initiated. The resident's inventory sheet confirmed the admission with specific clothing items. The Housekeeping Supervisor was unaware of the missing items, and a CNA acknowledged the resident's complaint but did not report it. The Director of Nursing stated that staff should check the inventory sheet and initiate a grievance if items were not found, but this procedure was not followed.
Failure to Provide Communication Support for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide appropriate communication treatment and services for a resident with hemiparesis and hemiplegia following a stroke, who was moderately cognitively impaired and had moderate difficulty hearing. The resident's preferred language was Vietnamese, and they required an interpreter to communicate with healthcare staff. Despite these needs being documented in the resident's care plan, the facility did not provide the necessary communication aids, such as cue cards, and the phone number for the translation service was non-functional. Observations revealed that the resident was unable to effectively communicate with staff, as they could only nod in response to basic questions and were not aware of the communication aids that should have been available. Interviews with staff indicated a lack of awareness and use of the translation services and communication aids specified in the resident's care plan. Staff members admitted to not using a translator and were unaware of the availability of cue cards or boards for the resident. Additionally, the resident's care plan was missing necessary interventions related to their hearing impairment, and the picture board that was initially provided was not replaced after it went missing. This lack of adherence to the care plan and failure to provide appropriate communication support placed the resident at risk for diminished quality of life and potential decline in their ability to perform activities of daily living.
Failure to Provide Adequate Bathing for Resident
Penalty
Summary
The facility failed to provide adequate bathing for a resident who was dependent on staff assistance for showers. The resident, who was cognitively intact and had a diagnosis of neuromuscular dysfunction of the bladder, was scheduled to receive showers on Monday and Friday evenings. However, documentation revealed that the resident was not offered showers on several scheduled days, and when the resident refused a shower, there was no evidence that the staff reoffered the shower or reported the refusal to a nurse. The resident expressed dissatisfaction with the frequency of showers, stating that staff were often too busy or offered showers at inconvenient times without prior notice. Interviews with staff members revealed inconsistencies in the implementation of the facility's policy regarding reoffering showers. Some staff admitted to not having time to assist the resident with showers if the resident agreed late in the shift, while others indicated that showers were offered at times when the resident was likely to refuse. The Director of Nursing Services confirmed the lack of documentation for reoffering showers and acknowledged the failure to adhere to the facility's protocol for handling shower refusals.
Failure to Provide Person-Centered Activities
Penalty
Summary
The facility failed to provide an ongoing person-centered activity program for two residents, leading to a deficiency in meeting their psychosocial needs. Resident 36, admitted with diagnoses including cardiomyopathy, dementia, restlessness, and anxiety disorder, expressed a desire to participate in various activities such as reading, puzzles, and outings. However, from October 20 to November 20, 2024, Resident 36 did not participate in any activities, as confirmed by activity logs and staff interviews. Observations revealed the resident was often in bed with no engagement in activities, and staff were unaware of the resident's preferences. Similarly, Resident 9, with a history of hemiparesis and hemiplegia following a stroke, was moderately cognitively impaired and preferred activities such as listening to Vietnamese music, reading, and participating in group activities. Despite these preferences, Resident 9 did not engage in any activities from October 21 to November 19, 2024. The resident reported language barriers and a lack of suitable materials and activities, such as large print newspapers and Vietnamese music, which hindered participation. Staff interviews indicated a lack of awareness of the resident's preferences and needs. The deficiency was further compounded by staffing issues, as the previous activity director left in September 2024, and the new director started in November 2024, resulting in minimal activities being offered. The activities assistant, working part-time, focused on familiar residents, neglecting others like Residents 36 and 9. The facility's failure to provide individualized and meaningful activities for these residents led to a decline in their psychosocial well-being and quality of life.
Failure to Follow Physician Orders for Pain Management
Penalty
Summary
The facility failed to adhere to physician orders for a resident with chronic pain and opioid dependency, leading to improper administration of oxycodone. The resident was prescribed 10 mg of oxycodone for severe pain rated between 7 to 10 on a pain scale and 5 mg for moderate pain rated between 4 to 6. However, the medication administration record (MAR) for November 2024 showed that the resident received 10 mg of oxycodone on four occasions when their pain was documented as 5 or 6, which was outside the prescribed parameters. Additionally, the resident was administered 5 mg of oxycodone on two occasions when their pain was documented as 7, which also did not align with the physician's orders. The Director of Nursing Services (DNS) confirmed these discrepancies upon reviewing the MAR, acknowledging that the resident received oxycodone outside of the physician's ordered parameters. This failure placed the resident at risk for ongoing pain or over-sedation.
Failure to Provide Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement necessary interventions to prevent pressure ulcers and skin breakdown for a resident who was at risk for such conditions. The resident, who was admitted with neuromuscular dysfunction of the bladder, was cognitively intact and identified as at risk for developing pressure ulcers. The resident's physician orders required wound care for skin tears on the thighs, and the resident was supposed to have a pressure-reducing device for the wheelchair. However, the resident was observed sitting on a folded towel instead of a proper cushion, which was necessary to prevent skin irritation and breakdown. Despite the resident's repeated requests for a suitable cushion, the facility failed to provide one that met the resident's needs. Staff members, including CNAs and an RN, acknowledged that the resident should have a cushion when in the wheelchair and confirmed the resident's complaints of discomfort. The DNS reviewed the resident's clinical record and confirmed the resident's risk for pressure ulcers, yet the appropriate intervention of providing a suitable cushion was not implemented, leading to the deficiency.
Failure to Provide Appropriate ROM Care
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent further decreases in range of motion for two residents, leading to a deficiency in care. Resident 9, who was admitted with hemiparesis and hemiplegia following a stroke, was observed to have contractures on the left side. Despite having a care plan that included the use of a left hand palm guard and therapy carrot, as well as daily range of motion exercises, documentation revealed that these interventions were not consistently applied. Observations showed that the resident's left hand was often without the necessary splint or brace, and staff interviews indicated a lack of clarity and consistency in implementing the resident's restorative program. Resident 10, who was readmitted with dementia and left-sided weakness, also experienced a lack of appropriate care for contracture management. The resident's clinical record lacked evidence of comprehensive assessment, ongoing monitoring, or any support or exercises to maintain or improve range of motion. Observations and staff interviews confirmed that the resident did not participate in any range of motion exercises and did not have any devices like a therapy carrot, splint, or brace for the left hand. Staff were unaware of any restorative program for the resident, and there was no care plan related to the management of the resident's upper extremity contractures. The deficiency was further highlighted by the lack of communication and coordination among staff members regarding the residents' care plans and restorative programs. Staff interviews revealed confusion about responsibilities and the absence of clear documentation to indicate whether restorative activities were offered or completed. The Director of Rehab confirmed that no referral had been received for Resident 10, and the Director of Nursing Services acknowledged the lack of assessment and care planning for the resident's contractures.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care to a resident who was a trauma survivor, leading to a deficiency in care. The resident, who had a history of PTSD and stimulant abuse, was admitted to the facility with significant trauma history, including a motor vehicle accident that resulted in paraplegia and the death of a child. Despite the facility's policy to screen for trauma and develop a care plan based on the resident's needs, the care plan for the resident's PTSD was not developed until 38 days after admission. This delay in care planning left the resident without appropriate interventions for managing PTSD symptoms and potential triggers. The resident experienced frequent anxiety and night terrors related to their PTSD, which were not adequately addressed by the facility. The resident reported various triggers, such as loud noises and certain television shows, which exacerbated their anxiety. Despite these known triggers, the care plan did not include specific interventions to mitigate these issues, and staff were not fully informed about the resident's needs. The resident also experienced an anxiety attack when their room became crowded and loud, further highlighting the lack of a comprehensive care plan. Interviews with staff revealed a lack of awareness and communication regarding the resident's PTSD and anxiety triggers. The Social Services Director had not conducted a thorough follow-up assessment since the resident's admission, and the Director of Nursing Services confirmed the care plan was incomplete. Staff members were unaware of the resident's night terrors and anxiety attacks, indicating a failure to provide consistent and informed care. This lack of trauma-informed care placed the resident at risk for re-traumatization and decreased their quality of life.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident diagnosed with PTSD and stimulant abuse. The resident, who was admitted in September 2024, had a history of a traumatic motor vehicle accident resulting in paraplegia and experienced PTSD symptoms such as night terrors and panic attacks. Despite these needs, the facility did not offer the resident mental health services, peer support, or participation in Narcotics Anonymous meetings, nor did they assist with obtaining the Affect App, which could aid in addiction recovery. The resident's care plans were not person-centered and did not accurately reflect the resident's behaviors or needs. The behavior care plan included interventions for behaviors the resident did not exhibit, such as yelling and crying, and the psychosocial-emotional care plan lacked individualized strategies to address the resident's PTSD and anxiety. The facility's social services director admitted to not having asked the resident about their interest in additional mental health support beyond an initial inquiry at admission. On November 19, 2024, the resident received a PRN medication for anxiety, but there was no documentation explaining the cause of the anxiety or any non-pharmacological interventions attempted. Staff members, including the social services director and the director of nursing services, were unaware of the resident's anxiety attack and the lack of person-centered care planning. The resident expressed dissatisfaction with the facility's lack of support for their PTSD and anxiety, stating that they had not been offered counseling or therapy services since admission.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to accommodate the food preferences of a resident, identified as Resident 37, who was admitted with neuromuscular dysfunction of the bladder and was cognitively intact. Upon admission, the resident expressed specific food preferences, including a dislike for peas, green beans, pepper, raisin bread, and raisins, and a preference for oatmeal for breakfast and a salad with meals. Despite these documented preferences, the resident was repeatedly served meals containing disliked items such as green beans and gravy, and was not provided with the requested salad. On multiple occasions, the resident was observed refusing meals due to the presence of disliked items, such as green beans and gravy, which were not supposed to be included according to the resident's meal ticket. The dietary staff, including the cook and the Dietary Director, acknowledged the resident's preferences but failed to adhere to them. The cook admitted to serving beef coated in gravy despite knowing the resident's dislike for it, and the Dietary Director confirmed that the resident should not have been served such meals. The facility administrator acknowledged the findings but did not provide additional information.
Failure to Prevent Access to Excessively Hot Liquids
Penalty
Summary
The facility failed to ensure that cognitively impaired residents did not have access to excessively hot liquids, resulting in a second-degree burn for one resident. The incident involved a resident who was admitted with diagnoses including diabetes. On a specific date, an agency CNA notified an LPN that the resident had spilled hot coffee on their lap. A subsequent facility investigation revealed that the nursing staff had taken the coffee cart out of the kitchen before the coffee had cooled to a safe temperature, leading to the resident being served coffee that was too hot, above 155 degrees Fahrenheit. The resident was later assessed to have a second-degree burn on their right lateral thigh, characterized by a large area of reddened skin with several ruptured blisters and clear fluid drainage, and the resident reported experiencing pain. Interviews with dietary staff confirmed that the coffee was brewed too hot to serve and was supposed to cool before being served to residents. The facility administrator acknowledged that staff had prematurely taken the coffee cart out, resulting in the burn incident, and confirmed that there were no other incidents related to hot coffee temperatures since then. Staff members also stated that coffee temperatures were not checked prior to the incident.
Removal Plan
- Policy/procedure change related to coffee preparation.
- Audit for other potentially affected residents.
- All staff education related to hot liquid safety.
- Audits of new process for distributing hot beverages to ensure completion.
- Coffee machine brew temperature lowered.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Portland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gateway Care And Retirement | 0.2 mi | ★★★★★ | 0 | 0 |
| Rose City Nursing And Rehabilitation | 0.7 mi | ★★★★★ | 1 | 0 |
| Marquis Mill Park | 0.9 mi | ★★★★★ | 13 | 0 |
| Menlo Park Post Acute | 1 mi | ★★★★★ | 15 | 0 |
| Portland Health And Rehabilitation | 1.1 mi | ★★★★★ | 21 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.