Menlo Park Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Portland, Oregon.
- Location
- 745 Ne 122nd Avenue, Portland, Oregon 97230
- CMS Provider Number
- 385044
- Inspections on file
- 30
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Menlo Park Post Acute during CMS and state inspections, most recent first.
The facility did not conduct annual performance reviews for five CNAs, as required for competent staffing. Personnel records showed that CNAs hired between 2008 and 2017 had not received evaluations, a fact confirmed by HR/Payroll staff.
The facility did not ensure CNA staff received the required 12 hours of annual in-service training. Five CNAs were found to have incomplete training hours, with two having zero hours, two having 8 hours, and one having 11 hours. This was confirmed by HR and acknowledged by the Administrator.
The facility failed to provide a homelike dining environment by serving meals with plastic spoons, glasses, and Styrofoam cups. A resident expressed dissatisfaction with the plastic utensils, and staff confirmed the use of these items due to a shortage of regular cutlery. Multiple residents complained about the dining experience feeling like a fast food restaurant.
The facility failed to secure medication and treatment carts, leaving them unlocked and unattended on multiple occasions. This included carts containing prescription medications, inhalers, wound treatment supplies, and insulin. These lapses were confirmed by staff and reported to the Interim DNS.
The facility was found to have unsanitary conditions in the kitchen, with a pink/black substance on the ice machine and a black substance with clear slime in the ice scoop container. The Maintenance Director and Administrator acknowledged these issues, indicating a need for cleaning.
A resident reported being inappropriately touched by another resident, but the facility failed to report the allegation to the State Agency within the required two-hour timeframe. The delay was due to staff misunderstanding the reporting requirements and being unable to reach a nurse manager. The incident involved two residents with intact cognition, and the failure to report promptly placed residents at risk.
The facility failed to inform two residents and/or their representatives about the risks and benefits of psychotropic medications and did not obtain informed consent before administration. Despite the facility's policy requiring informed consent, Resident 34 received buspirone, sertraline, and clonidine, and Resident 66 received quetiapine without documented consent. The Interim DNS confirmed the expectation for nursing staff to review medication risks and benefits with residents prior to administration.
A resident with moderate cognitive impairment was verbally abused by another resident who was cognitively intact. The incident involved yelling and swearing, witnessed by staff and a family member. The affected resident felt scared and confused, while the aggressor admitted to losing control of emotions.
A facility failed to provide written transfer notices with appeal rights to a resident and their representative, and did not notify the State LTC Ombudsman of the resident's hospitalization. The resident, admitted with complications from a heart catheterization, was transferred to the hospital without the required notifications. Staff interviews revealed that the responsibilities for these notifications were not fulfilled, placing residents at risk of not being informed about their options and rights.
A facility failed to provide a resident with a written notice of its bed hold policy upon transfer to a hospital. The resident, admitted with complications from a heart catheterization, was transferred without receiving the required notice. The Interim DNS confirmed the oversight, noting the charge nurse was responsible for providing the policy.
The facility failed to follow physician orders for three residents, leading to potential adverse medication consequences. A resident with major depression and diabetes did not have their blood pressure and heart rate assessed before receiving clonidine and metoprolol, as required. Another resident with major depressive disorder missed applications of prescribed topical medications and doses of Protonix. A third resident with high blood pressure and sleep apnea received Prozasin despite having a systolic blood pressure below the prescribed threshold. Staff interviews confirmed these deficiencies.
A resident with major depression and diabetes consented to a vision examination, but the facility failed to schedule it, leaving the resident without glasses. Despite multiple requests from the resident, the examination was not completed, and staff confirmed the oversight.
A facility failed to provide trauma-informed care for a resident with PTSD and major depressive disorder. Despite being admitted in July 2022, the resident's PTSD was not assessed, and no care plan was developed to address potential trauma triggers. Staff interviews confirmed that trauma screenings should have been completed at admission, particularly for residents with PTSD, but this was not done.
A resident with moderate cognitive impairment was observed smoking unsupervised in the courtyard, contrary to the facility's Smoking Policy requiring supervision for residents who do not meet safety criteria. This lack of supervision posed a risk of injury from fire hazards.
A resident, who was cognitively intact and had chronic kidney disease and heart failure, reported loaning money to a former CNA, which was not repaid. The facility initiated an investigation and suspended the staff member, but the staff member was no longer employed and could not be interviewed. The administration was informed of the findings but provided no further information.
Failure to Conduct Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received their annual performance reviews, which is a requirement for maintaining sufficient and competent staffing. During a review of personnel records conducted on November 6, 2024, it was found that five randomly selected CNAs, identified as Staff 6, 7, 8, 9, and 10, had not received their annual performance evaluations. These CNAs had hire dates ranging from 2008 to 2017, yet none had completed performance reviews. This oversight was confirmed by Staff 23, who is responsible for Human Resources and Payroll, indicating a lapse in the facility's processes for evaluating staff performance.
Deficiency in CNA Annual Training Hours
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistant (CNA) staff received the required 12 hours of annual in-service training, as evidenced by a review of training records and interviews. Specifically, five randomly selected CNA staff members did not meet the training requirement. Staff 6 and Staff 9 had zero hours of annual training, while Staff 7 and Staff 10 each had only 8 hours, and Staff 8 had 11 hours. This deficiency was confirmed by Staff 23 from Human Resources/Payroll, who provided the list of training hours, and acknowledged by Staff 1, the Administrator, who confirmed the requirement for 12 hours of annual in-service training for CNA staff.
Failure to Provide Homelike Dining Environment
Penalty
Summary
The facility failed to ensure a homelike environment for residents during dining, as observed between 11/5/24 and 11/8/24. Meals were served using plastic spoons, plastic glasses, and Styrofoam cups, which residents and staff identified as not homelike. Resident 66 expressed dissatisfaction with the plastic utensils, describing them as inadequate. Staff 29, a CNA, confirmed that residents typically received regular cutlery but had been using plasticware for at least a month. Staff 30, the Dietary Manager, acknowledged the lack of sufficient glasses, cups, and silverware for meal service, leading to the use of plastic and Styrofoam items. Staff 13, the Activities Director, reported multiple resident complaints about the dining experience resembling a fast food restaurant rather than a homelike setting.
Medication and Biologicals Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications and biologicals were securely stored, as required by their policy. Observations revealed that medication and treatment carts were left unlocked and unattended on multiple occasions. On Hall 1, a treatment cart was found unlocked without the nurse in view, and this was confirmed by an LPN. Similarly, on Hall 3, a medication cart containing prescription medications and inhalers was left unlocked and unattended, which was also confirmed by another LPN. Additionally, a treatment cart on Hall 1 was observed to be unlocked and unattended, containing wound treatment supplies, equipment for checking blood sugar levels, and residents' insulin. An LPN confirmed this lapse. Furthermore, both a treatment cart and a medication cart were found near the south entrance, with the treatment cart unlocked and the computer on the medication cart open to a resident's medical record, both unattended. These findings were confirmed by an RN, and the Interim DNS was notified of these issues.
Unsanitary Conditions in Ice Machine and Scoop
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, specifically concerning the ice machine and ice scoop. During an observation, a pink/black substance was found on a plastic shield inside the ice machine, with condensation dripping over it onto the ice. The Maintenance Director confirmed that the ice machine was cleaned monthly but acknowledged the presence of the substance, indicating it should be free of debris or contaminants. Additionally, the ice scoop was stored in a container with a black substance and clear slime at the bottom. Both the Maintenance Director and the Administrator acknowledged the unsanitary conditions of the ice machine and scoop container, recognizing the need for cleaning.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to timely report an allegation of sexual abuse involving two residents to the State Agency (SA). Resident 60, who had intact cognition and was admitted with a C-difficile infection, reported that Resident 13, also with intact cognition and admitted with diabetes and alcohol-induced cirrhosis, touched her/his genital area while she/he was asleep. The incident was reported to the facility staff on the morning of 10/27/24, but the SA was not notified until 11:05 AM, which was beyond the required two-hour timeframe for reporting such allegations. The delay in reporting was due to a misunderstanding of the reporting requirements by the facility staff. Staff 1, the Administrator, believed there was a 24-hour window for reporting unless there was serious bodily injury, and Staff 24, an LPN, was not familiar with the two-hour reporting requirement. Additionally, Staff 24 attempted to contact a nurse manager but was unsuccessful, leading to further delays. The Interim DNS acknowledged the confusion regarding the reporting timeframe, which resulted in the failure to report the allegation within the mandated period.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform residents and/or their responsible parties about the risks and benefits of psychotropic medications and did not obtain informed consent before administering these medications. This deficiency was identified for two residents who were part of a sample reviewed for unnecessary medications. The facility's policy on psychoactive medications, dated 8/1/24, mandates that informed consent must be obtained from the resident or their representative prior to the administration of any psychoactive medication. Resident 34, admitted in March 2023 with a diagnosis of major depressive disorder, was administered buspirone, sertraline, and clonidine without documented evidence of informed consent. Similarly, Resident 66, admitted in October 2024 with major depressive disorder, received quetiapine without documented consent. The Interim Director of Nursing Services (DNS) confirmed that it was expected for nursing staff to review the risks and benefits of psychotropic medications with residents before administration, which did not occur in these cases.
Verbal Abuse Incident Between Residents
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse, as evidenced by an incident involving two residents. Resident 19, who was admitted with diagnoses including infection and anxiety disorder and had moderate cognitive impairment, was verbally abused by Resident 17. Resident 17, who was cognitively intact and admitted with diagnoses including amputation and obesity, entered Resident 19's room and yelled and swore at them, demanding that they stop yelling and turn down their TV. This interaction was witnessed by several staff members and a family member. Staff members, including a Physical Therapy Assistant and a CMA, observed the incident and confirmed that Resident 17 shouted and cursed at Resident 19. Resident 19 expressed feeling scared and confused about the situation. Resident 17 admitted to having a tendency to lose control of their emotions and acknowledged yelling at Resident 19. The incident was reported to the facility's Administrator and Interim DNS, who were informed of the findings of the investigation.
Failure to Provide Transfer Notices and Notify Ombudsman
Penalty
Summary
The facility failed to provide written transfer notices with appeal rights to residents and their representatives, and did not notify the Office of the State Long-Term Care Ombudsman of resident hospitalizations. This deficiency was identified during the review of a case involving a resident who was admitted to the facility with complications from a foreign body left in the body following a heart catheterization. The resident was transferred to the hospital, but there was no evidence in the health record that a transfer notice with appeal rights was provided to the resident or their representative, nor was the Ombudsman notified of the transfer. Interviews with facility staff revealed that the responsibility for notifying the Ombudsman and providing written transfer notices was not fulfilled. Staff 28, responsible for notifying the Ombudsman, admitted to not having done so since August 2024. Additionally, Staff 2, the Interim Director of Nursing Services, confirmed that the charge nurse was supposed to complete the written notification of transfer, but this was not done for the resident in question. This lack of action placed residents at risk of not being informed about their options and rights during transfers.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide a written notice of its bed hold policy to a resident or their representative at the time of transfer to a hospital. This deficiency was identified during a review of the health record of a resident who was admitted to the facility in September 2024 with complications from a foreign body left in the body following a heart catheterization. The resident was transferred to the hospital on October 8, 2024, but there was no evidence in the health record that a written bed hold policy was provided at the time of transfer. Staff 2, the Interim Director of Nursing Services, confirmed that the charge nurse was responsible for providing this notice and acknowledged that it was not given to the resident upon transfer.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to ensure physician orders were followed for three residents, leading to potential adverse medication consequences. Resident 34, diagnosed with major depression and diabetes, was prescribed clonidine and metoprolol succinate ER with specific instructions to hold the medication if the systolic blood pressure (SBP) was less than 110 and/or heart rate (HR) was less than 55. However, the medication administration record (MAR) did not indicate that the resident's SBP and HR were assessed before administering these medications, as confirmed by staff interviews. This oversight was attributed to the MAR not being set up to alert staff to check these vital signs before medication administration. Resident 66, with a diagnosis of major depressive disorder, was prescribed Clindamycin Phosphate External and Diprolene External Ointment, both of which were not applied according to physician orders on multiple occasions. Additionally, Protonix, prescribed for gastric reflux, was not administered on several days despite being available in the facility's automated medication dispensing system. Staff interviews confirmed the missed applications and administrations, with no documentation explaining the omissions in the resident's health record. Resident 8, diagnosed with high blood pressure and sleep apnea, was prescribed Prozasin with instructions to hold the medication if the SBP was less than 110. The MAR revealed that Prozasin was administered on days when the resident's SBP was below the specified threshold, as confirmed by staff. This indicates a failure to adhere to physician orders, potentially placing the resident at risk for adverse effects. Staff interviews corroborated the findings, and no additional information was provided to explain the discrepancies.
Failure to Schedule Vision Examination for Resident
Penalty
Summary
The facility failed to assist a resident in obtaining necessary vision care, which placed the resident at risk for impaired vision. The resident, admitted in March 2023 with diagnoses including major depression and diabetes, consented to a vision examination in December 2023. However, a review of the resident's health record showed no evidence that the examination was scheduled or completed. Observations over several days in November 2024 revealed the resident was not wearing glasses. The resident reported that they were supposed to receive glasses the previous year but had not been scheduled for an examination despite multiple requests. Staff confirmed that the examination was authorized but never scheduled, indicating a lapse in the facility's process for managing the resident's vision care needs.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with Post-traumatic stress disorder (PTSD) and major depressive disorder. The resident was admitted in July 2022, but the Social Services Assessment conducted shortly after admission did not assess the resident's PTSD diagnosis. Furthermore, the resident's clinical record lacked evidence of a trauma assessment or a care plan addressing potential trauma triggers. Interviews with facility staff revealed that trauma screenings were supposed to be completed at admission, especially for residents with PTSD, but this was not done for the resident in question.
Failure to Supervise Resident During Smoking Activities
Penalty
Summary
The facility failed to ensure appropriate supervision for a resident with moderate cognitive impairment while smoking, which posed a risk of injury from fire hazards. The facility's Smoking Policy required residents who did not meet safety criteria to be supervised during smoking activities. Resident 106, who had diagnoses including diabetes mellitus and stroke, was identified as having moderate cognitive impairment with a BIMS score of 11. A Smoking Safety Evaluation indicated that the resident lacked adequate cognitive skills, did not recognize designated smoking areas, and could not identify proper smoking receptacles. Consequently, the resident was reassessed and designated as a supervised smoker. Despite this designation, on one occasion, Resident 106 was observed smoking a lit cigarette in the courtyard smoking area without any staff supervision. Staff 4, an LPN, confirmed the resident's presence in the smoking area without supervision. The facility's failure to provide the necessary supervision as per their policy placed the resident at risk for injury from fire hazards. The facility's administration was informed of these findings, but no additional information was provided.
Misappropriation of Resident's Property by Staff
Penalty
Summary
The facility failed to protect a resident from the misappropriation of property, specifically involving a financial transaction with a staff member. Resident 106, who was cognitively intact with a BIMS score of 15, had been admitted to the facility with chronic kidney disease and heart failure. The resident reported loaning money to a former CNA, identified as Staff 4, on several occasions. While previous loans were repaid, a loan of $700 made in May 2023 for new tires was not returned. The facility was aware of the situation and had initiated an investigation, which included suspending Staff 4. However, Staff 4 was no longer employed at the facility and could not be interviewed. The facility's administration and DNS were informed of the misappropriation findings but did not provide additional information.
Latest citations in Oregon
A resident with acute respiratory failure and heart failure had a documented Full Code status and a POLST specifying Attempt Resuscitation/CPR and Full Treatment. During night rounds, two CNAs found the resident not breathing, cool to the touch, with yellow skin and no pulse, but did not initiate CPR or call a code blue, instead going to notify an LPN. The LPN assessed the resident, confirmed absence of vital signs, noted the body was cold with mottling and no rigor mortis, and contacted the DNS, physician, and 911 for the coroner’s number, but did not start CPR or activate a code blue. No lifesaving measures were attempted despite facility policy requiring CPR for unresponsive residents without a valid DNR and the resident’s clearly documented full code status, leading surveyors to cite Immediate Jeopardy and substandard quality of care.
A resident with respiratory failure and pneumonia, who was Full Code and not on hospice, was found during routine rounds and suspected to be deceased. Nursing staff assessed the resident, noted there was no rigor mortis, confirmed death, and did not initiate a code blue or any resuscitation efforts despite the resident’s Full Code status. The facility later treated this as a potential neglect incident but did not report it to the State Agency within the required two-hour timeframe, as confirmed by the regional QA director.
A resident with chronic pain and a left below-knee amputation, who required supervision or touching assistance with ADLs, was discharged after returning from an outing shortly after midnight. Although discharge instructions noted the need for assistance and assistive devices, there was no documentation of referrals for medical equipment or home health services. Facility staff documented that the resident was discharged because they were out past midnight and believed Medicare would not cover the stay, did not issue a NOMNC, and recorded the discharge as voluntary despite the resident later reporting they had been “kicked out” and were sleeping on a friend’s couch with difficulty getting around. Staff interviews revealed no financial issues and indicated the resident had originally been scheduled for discharge at a later date.
A resident with a hip fracture and anxiety reported to social services that a CNA had been rough, told the resident to take themself to the bathroom, and instructed them not to get out of bed until a specified early morning time. The allegation was received by facility staff in the late afternoon, but the incident report was not submitted to the State Agency until the following day, exceeding the required 2-hour reporting timeframe acknowledged by the DNS. The deficiency concerns this untimely reporting of an abuse allegation, despite the CNA’s denial of any abuse.
A resident with hemiplegia, previously evaluated as not appropriate to self-administer any medications, was found to have open tubes of antifungal cream, anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) stored in a bedside drawer. Record review showed there were no MD orders for several of these topical products and no order permitting self-administration. An RN case manager confirmed the absence of orders, and the resident reported self-administering the medications, demonstrating a failure to ensure medications were administered only as ordered and in accordance with the resident’s assessed ability.
A resident with hemiplegia, previously evaluated as not appropriate to self-administer medications, was found with open containers of anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) in a bedside drawer. Record review showed no MD orders, no documented indication for use, and no monitoring for these medications. An RN case manager confirmed there were no orders and that staff did not administer or monitor the creams, while the resident reported self-administering them.
The facility failed to investigate multiple staff-reported allegations that one cognitively intact, wheelchair-using resident engaged in sexually inappropriate behaviors toward three other residents with significant cognitive and neurological impairments. Staff reported finding a resident with a ripped brief, crying and resisting care, and suspected sexual contact; they also reported that the alleged aggressor tried to take another resident into a shower room for sexual acts, attempted to video and kiss that resident, and encouraged a third resident to remove their top while present with a phone. CNAs, social services, and other staff stated they informed the administrator, DNS, HR, and unit management about these incidents and behaviors, but the administrator acknowledged that no investigations were conducted, despite being aware of the reports.
A resident with multiple sclerosis, care planned as dependent on two staff and requiring a Hoyer lift for transfers, was instead transferred by a CNA using a stand-pivot method without the lift or a second staff member. The CNA reported she had not read the resident’s care plan and described performing the transfer by giving the resident a “giant bear hug” and making several attempts to move the resident from chair to bed. The resident reported right flank pain and stated the transfer caused three broken ribs, although an x-ray later showed no rib fractures or dislocation and no visible injury was noted.
A resident with multiple sclerosis was admitted with physician orders for PT and OT, but review of the clinical record showed no documentation that these therapies were ever provided. The resident reported not receiving any therapy since admission, and the Director of Rehabilitation confirmed that no therapy services had been delivered during this period despite active orders, resulting in a failure to provide ordered rehabilitative services.
A dependent resident with dementia and a history of stroke, identified on the MDS as requiring staff assistance for showers, did not consistently receive scheduled bathing, and one CNA falsely documented that bathing had been provided. CNA task reports showed missed or undocumented baths on scheduled days, and an internal investigation confirmed that a bath recorded as completed on one date had not actually occurred. Staff interviews indicated that if bathing was not documented it usually did not occur, and that scheduled bathing was expected to be provided by staff.
Failure to Initiate CPR for a Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide CPR in accordance with a resident’s documented full code status. The facility’s Emergency Procedure CPR policy, initiated in 2001, required staff trained in CPR to initiate resuscitation on unresponsive residents who were not breathing unless there was a valid DNR order or clear signs of irreversible death such as rigor mortis. The policy further specified that if a resident’s DNR status was unclear, CPR should be started and continued until a DNR was confirmed. Resident 3 had been admitted with diagnoses including acute respiratory failure and heart failure and had a care plan and POLST on file indicating Full Code/Attempt Resuscitation and Full Treatment, including use of intubation, advanced airway interventions, mechanical ventilation, and transfer to hospital or ICU if indicated. On the night of the incident, a CNA (Staff 5) documented last vital signs for the resident at approximately 10:45 PM, with oxygen saturation of 92% on one liter of oxygen. At 2:00 AM, the resident was observed sleeping, breathing, and with a dry brief. Around 4:00 AM, Staff 5 and another CNA (Staff 8) entered the resident’s room and observed that the resident was not breathing, had yellow skin color, was cool to the touch, and had no palpable pulse. Both CNAs concluded the resident was deceased and went to notify the LPN (Staff 4) instead of initiating CPR or calling a code blue, despite having recent CPR training and later stating that, in retrospect, they would have started CPR and called for a code blue. When Staff 4 (LPN) entered the room, she assessed the resident and found no pulse, blood pressure, or respirations, noted the body was cold, with some mottling on the lower legs, pale/yellowish skin color, and no rigor mortis. Staff 4 did not initiate a code blue or CPR and instead contacted the DNS (Staff 2) and the physician, and then called 911 to obtain the coroner’s phone number. No lifesaving measures were attempted by any staff, despite the resident’s documented full code status and the facility policy requiring CPR in the absence of a valid DNR or signs of irreversible death. The DNS later stated she expected staff to call a code blue immediately, start CPR, call 911, and verify the resident’s code status. Surveyors determined that the facility failed to provide CPR according to the resident’s code status, placing all residents with full code status at risk and constituting substandard quality of care, with the noncompliance cited as Immediate Jeopardy and Past Noncompliance.
Removal Plan
- Administrator, DNS and nursing staff would be re-educated on the code blue process, how to locate a resident's code status in PCC and the POLST on file, and the importance of following individual resident care plans and orders.
- Resident code status would be cross-referenced with the PCC order, POLST scanned in binder, care plan, and resident dashboard.
- DNS or designee would monitor resident code status preferences for new admissions/returning admissions from hospitalizations.
- DNS or designee would audit code status for all new admissions and readmissions from hospitalization or ED visits, and share audit results with the QAPI committee to ensure substantial compliance is maintained.
- DNS or designee would complete a mock code.
- DNS or designee would complete mock codes.
Failure to Timely Report Alleged Neglect Involving Lack of CPR for Full Code Resident
Penalty
Summary
The facility failed to timely report an allegation of potential neglect related to CPR to the State Agency for one resident. The resident was admitted in February 2026 with diagnoses including respiratory failure and pneumonia and had a Full Code status, was not on hospice, and therefore was to receive CPR if found unresponsive. According to the facility’s investigation dated six days after the resident’s death, staff found the resident during routine rounds and suspected the resident was deceased, notified the nurse, and the nurse confirmed the resident was deceased. The investigation documented that at the time of the nurse’s assessment the resident did not have rigor mortis, yet the nurse did not initiate a code blue or any resuscitation interventions despite the Full Code status. The incident, which occurred on an identified date, was not reported to the State Agency until a later identified date, and the Regional Director of Quality Assurance confirmed that the facility did not report the incident within the required two-hour timeline. This failure to timely report the allegation of potential neglect involving the lack of CPR initiation for a Full Code resident constituted the deficiency identified by surveyors.
Failure to Ensure Safe and Orderly Discharge After Late Return from Outing
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and orderly discharge for a resident who was admitted with chronic pain, a left below-knee amputation, and post-surgical aftercare needs. An admission MDS completed shortly after admission documented that the resident was cognitively intact but required supervision or touching assistance with toileting, transfers, and bathing. Discharge instructions indicated the resident was being discharged home and that the resident’s current physical status required assistance and assistive devices, yet there was no documentation of referrals for needed medical equipment or a home health referral. The facility’s records did not show that these services or equipment were arranged prior to discharge. On the night in question, a nursing note documented that the resident returned to the facility after an outing at 12:23 AM, after the facility had notified the police because the resident’s location was unknown. The resident reported having been out with friends and being unaware of any concern. A social services note stated that because the resident was out past midnight, the resident was discharged from the facility, and a NOMNC was not issued because the resident left prior to the scheduled discharge and on their own initiative. A discharge summary documented that discharge instructions were reviewed with the resident, who refused to sign and was leaving voluntarily, and the voluntary consent form included a handwritten statement that the resident refused to sign. Later, the resident stated they had been “kicked out” for coming back late and were sleeping on a friend’s couch, finding it difficult to get around. Staff interviews showed there were no financial issues documented, that staff believed Medicare would not cover the resident if out past midnight, and that the resident had been scheduled for discharge several days later, while a regional director later characterized the situation as a clerical error and confirmed a normal discharge should have been completed.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to timely report an allegation of abuse to the State Agency after a resident reported that a CNA had been rough and verbally directive with them. The resident, who had been admitted with diagnoses including a hip fracture and anxiety, stated that the CNA was “kind of rough,” told the resident to take themself to the bathroom, and instructed the resident not to get out of bed until 6:00 AM. The resident reported this allegation of abuse involving the CNA to the social services staff member at 4:00 PM on 1/29/26. According to the facility’s investigation documentation, the allegation was received by staff at 4:00 PM on 1/29/26, and the Facility Reported Incident form was not received by the State Agency until 2:13 PM on 1/30/26. The DNS acknowledged that the facility became aware of the allegation at 4:00 PM on 1/29/26 and that it should have been reported to the State Agency within two hours but was not. The CNA denied abusing the resident or any resident, but the deficiency centers on the delay in reporting the allegation to the State Agency within the required timeframe.
Failure to Prevent Unauthorized Self-Administration of Non-Prescribed Medications
Penalty
Summary
Surveyors identified that a resident was self-administering non-prescribed topical medications despite a documented determination that they were not appropriate to self-administer any medications. The resident, admitted with hemiplegia, had a Self-Medication Administration Evaluation dated 11/13/25 indicating they were not appropriate to self-administer medications. During an observation on 3/19/26 at 7:50 AM with a RN case manager, open tubes of antifungal cream, anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) were found in the resident’s bedside table drawer. Review of the clinical record showed there were no physician orders for the anti-itch cream, hydrocortisone cream, or DMSO, and the resident did not have an order to self-administer any medications. The RN case manager confirmed the lack of orders for these medications, and at 8:10 AM the resident stated they did self-administer the medications found in their room. This constituted a failure by the facility to ensure the resident did not self-administer non-prescribed medications and to provide treatment and care according to physician orders and the resident’s evaluated ability to self-administer medications.
Unmonitored Self-Administration of Topical Medications Without Physician Orders
Penalty
Summary
The facility failed to ensure a resident’s drug regimen was free from unnecessary drugs by not providing adequate monitoring, indication for use, or physician orders for multiple medications. A resident admitted with hemiplegia in May 2024 had a self-medication administration evaluation dated 11/13/25 indicating they were not appropriate to self-administer any medications. During an observation on 3/19/26, an RN case manager found an open tube of anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) in the resident’s bedside table drawer. Record review showed no physician orders, no documented indication for use, and no monitoring for these medications. The RN case manager confirmed the resident did not have orders for the anti-itch cream, hydrocortisone cream, or DMSO, and that staff did not administer or monitor these medications. The resident stated they self-administered the medications found in their room, despite the prior evaluation determining they were not appropriate to self-administer any medications.
Failure to Investigate Multiple Allegations of Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to investigate multiple allegations of sexual abuse involving three residents. Resident 102, who had cognitive loss equivalent to a young child, legal blindness, and was non-verbal, was reportedly found with a ripped brief, crying, and resisting a brief change. Staff reported concerns that another resident, Resident 105, had performed or attempted to perform sexual acts on Resident 102. Staff members, including CNAs and social services, stated they informed facility management, including the Administrator and DNS, about the torn brief, Resident 102’s distress, and concerns that Resident 105 was being sexually inappropriate with multiple residents. Despite these reports and discussions in morning meetings, the Administrator acknowledged that no investigation was completed, believing the incident was based on staff assumptions. The facility also failed to investigate allegations involving Resident 103, who had Alzheimer’s disease and Parkinson’s disease. Staff reported that Resident 105 attempted to take Resident 103 into a shower room to perform sexual acts, and that a staff member intervened. The complainant later spoke with Resident 103, who stated that Resident 105 was “sick” and made bad comments. Other staff reported to human resources, the DNS, and the Administrator that Resident 105 attempted to take a resident into a shower room to unclothe the resident, and that Resident 105 attempted to video Resident 103, expressed a desire to kiss Resident 103, and get the resident into a shower room. The Social Service Director confirmed she reported these concerns to the Administrator, who stated he was aware of the incident but that no investigation was completed. A third failure to investigate involved Resident 108, who had Huntington’s disease and dementia. A staff member reported observing Resident 105 telling Resident 108 to take off their shirt and gesturing for them to do so, and stated they completed a written statement and gave it to the unit manager. Another CNA reported hearing that Resident 105 and other residents were laughing and encouraging Resident 108 to remove their top, and also reported observing Resident 105 rubbing other residents’ backs more physically than appropriate. Social services reported being told that Resident 108 was removing their top while Resident 105 was in the dining room with a phone, and that Resident 105 admitted to the behavior but described it as innocent. The Administrator stated he was aware of Resident 108 removing their shirt while Resident 105 was present, yet confirmed that no investigation was completed for this incident. These failures to investigate led surveyors to determine that the facility did not respond appropriately to alleged violations of sexual abuse for the three residents.
Removal Plan
- Residents 102, 103, and 108 received head-to-toe skin assessments completed by RCMs with no observed findings.
- Resident 105 was placed on one-to-one observations pending investigations.
- Staff 1 (Administrator) and Staff 2 (DNS) were re-educated on the facility's abuse policy, reporting, and thorough investigations.
- Social Services will interview all interviewable residents regarding abuse.
- Nurses will complete a head-to-toe assessment on all non-interviewable residents.
- All staff, including agency staff, will be re-educated on the facility's abuse policy and reporting.
Failure to Follow Care-Planned Hoyer Lift Transfer Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow a resident’s care plan interventions for transfers, resulting in a transfer being performed without required equipment and assistance. A resident admitted in February 2026 with multiple sclerosis had a 2/25/26 ADL care plan indicating the resident was dependent on two staff members for transfers and required use of a Hoyer (mechanical) lift. Despite this, on 2/28/26 a CNA (Staff 3) performed a stand-pivot transfer without the Hoyer lift and without a second staff member. The resident later reported that Staff 3 gave a “giant bear hug” and made several attempts to transfer the resident from chair to bed, after which the resident reported right flank pain and stated the transfer caused three broken ribs. An x-ray on 3/10/26 showed no rib fractures or dislocation, and the resident was assessed to have no visible injury. During interview, Staff 3 confirmed she had completed a stand-pivot transfer with the resident and acknowledged she had not read the resident’s care plan, and the Administrator confirmed that the resident had been care planned for a two-person Hoyer lift transfer at the time of the incident.
Failure to Provide Ordered Rehabilitative Services
Penalty
Summary
The facility failed to provide ordered rehabilitative services to a resident with multiple sclerosis. The resident was admitted in February 2026 with admission orders dated 2/24/26 for both physical therapy and occupational therapy. Review of the resident’s clinical record showed no documented evidence that any therapy services were provided as ordered. In an interview on 3/11/26 at 10:58 AM, the resident reported not having received any therapy since admission. During a separate interview on 3/11/26 at 10:40 AM, the Director of Rehabilitation confirmed that the resident had not received any therapy services from the date of admission through 3/11/26, despite the existing orders for physical and occupational therapy. This failure to implement the physician’s orders for rehabilitative services for this resident placed the resident at risk for a decline in range of motion.
Failure to Provide and Accurately Document Scheduled Bathing for a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a dependent resident received required assistance with activities of daily living (ADLs), specifically bathing, and inaccurate documentation that bathing had been provided. The resident, admitted in 10/2025 with dementia and stroke, had a 10/21/25 admission MDS indicating severe cognitive impairment and dependence on staff for showers. The facility’s 12/2025 CNA task report showed the resident was scheduled for bathing on day shift on Wednesdays and Sundays. On 12/24/25, the task report was blank for bathing, and on 12/28/25, the report documented that the resident received bathing and was dependent on staff for assistance. However, a 12/29/25 facility investigation determined the resident did not receive a bath on 12/28/25 and that it had been falsely documented that bathing occurred. A Facility Reported Incident form dated 12/31/25 further documented that on 12/28/25, a CNA (Staff 5) noted providing bathing to the resident but did not provide any type of bathing. Additional record review showed that the resident’s 3/2026 CNA task report contained no documentation that any type of bathing was provided on 3/11/26. Attempts to contact Staff 5 on 3/16/26 and 3/17/26 were unsuccessful. During interviews, another CNA (Staff 7) stated that on 12/28/25 she observed Staff 5 lay the resident down and, when she asked about bathing, Staff 5 said she would complete the resident’s bathing in the evening; Staff 7 stated she could not perform the resident’s bathing in the evening because she moved to a different hall on evening shift. Another CNA (Staff 21) stated that usually if bathing was not documented in the resident’s record, bathing did not occur. The Regional Nurse (Staff 31) stated that staff should provide scheduled bathing to residents.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
