Below average — CMS composite of the measures below.
The next survey window likely opens around January 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 Menlo Park Post Acute during CMS and state inspections, most recent first.
A resident with ESRD, conjunctivitis, and a perforated corneal ulcer did not receive ordered erythromycin ophthalmic ointment on multiple occasions. The MAR showed missed doses when the resident was at dialysis or absent from the home, and there was no documented evidence that the provider was notified. Staff interviews showed the CMAs documented the resident as out of the facility but did not communicate the missed eye medication to nursing staff.
Dishwasher temperatures were below the level required for sanitizing dishes and utensils, with the machine observed at 110*F while dirty dishes were being washed and the temperature log left blank. In addition, a resident refrigerator contained a bag of food labeled only with a resident name and room number, along with undated fruit, rotisserie chicken, and processed cheese. Staff gave conflicting accounts of who was responsible for labeling and discarding resident food, and the dietary director confirmed the food items were undated.
Late and incomplete MDS assessments were identified for three residents. One resident’s annual MDS remained in progress and was not signed or submitted, another resident’s admission MDS and Activities CAA did not fully assess leisure and activity preferences, and a third resident’s admission MDS was completed and signed past the required timeframe. Staff acknowledged the delays and incomplete assessment documentation.
Delayed Quarterly MDS Assessments: Multiple residents had Quarterly MDS assessments left in progress or submitted well after the ARD, including residents with pneumonia, rib fractures, CHF, ataxic gait, hemiplegia/hemiparesis after stroke, dementia, and metabolic encephalopathy. The RN MDS Coordinator acknowledged the assessments were not completed within the required timeframe, with some sections unfinished or additional data still needed, and the Administrator acknowledged the assessments were not completed timely.
Failure to Provide Resident-Centered Activities: A facility did not provide individualized activity programming for multiple cognitively intact residents with documented preferences for music, reading, pets, going outside, news, religion, and group activities. One blind resident was not informed of scheduled events such as music, Bingo, socials, or an outing, and staff acknowledged that activity materials provided were not appropriate for that resident. Other residents reported boredom, limited engagement, missing reading resources, and lack of access to preferred leisure items, while the Kardex care plans did not include activity interests or preferences for several residents.
Activities Program Not Directed by a Qualified Professional: The facility failed to have a qualified professional direct the activities program. The Activities Director stated she had recently been promoted and was unaware of the certifications, trainings, or qualifications required for the role, yet she was responsible for planning group and individual activities for residents. The Administrator confirmed the Activities Director had been in the role since 12/2025 and did not have the appropriate qualifications.
Improperly Contained Garbage and Overflowing Dumpsters: The facility failed to keep dumpsters closed and garbage contained in the designated storage area. Surveyors observed dumpsters repeatedly very full with trash overflowing, bags placed in front of the dumpsters, and miscellaneous trash items and gloves on the ground. The Dietary Director stated the dumpsters were shared by all employees, and the MDS/maintenance director stated garbage was supposed to be collected 6 days per week.
Failure to perform hand hygiene for staff and residents: A CNA was observed providing care to a resident on contact precautions, handling soiled linens, removing gloves, and moving to another room without cleaning hands. In the dining room, residents said they were not offered hand hygiene before lunch, and observation confirmed no hand hygiene was offered before meal service. The DNS stated residents would be expected to be offered hand hygiene prior to eating.
Failure to Assess Residents for Self-Administration of Medications: Two residents had medications left at bedside without completed self-administration assessments. One cognitively intact resident with a fracture diagnosis had Senna and Tums in a cup on the bedside table, and staff were unaware the resident was not authorized to self-administer. Another resident with ESRD had Musinex, Musinex PM, and saline nasal rinses at bedside without a lock box, and staff confirmed no self-administration assessment had been completed.
A resident’s right to privacy was not honored when Resident Council minutes and staff responses included the resident’s name and APS-related information about alleged misappropriation of funds. The Activity Director confirmed the written responses were read aloud exactly as written to the resident group, and the Social Services Director confirmed the resident’s name was documented in the response. The resident, who was cognitively intact and had HF, stated feeling angry after hearing the information read out loud to everyone.
Failure to provide appropriate foot care for two residents. One resident with DM had weekly nail care orders, but was observed with a red, swollen foot and overgrown, curved toenails, and stated staff did not assess the foot or trim the nails. Another resident with PVD had a care plan for routine podiatry care, but no documentation showed podiatry visits, and the resident’s toenails were thick, yellowed, and very long. Staff confirmed nail care and podiatry services were not provided as expected.
Failure to Assess Trauma-Informed Care for Residents with PTSD: Two residents with PTSD and anxiety did not have resident-specific trauma assessments or care plan interventions documented. One resident reported loud knocking triggered a startled response and night terrors, yet staff continued loudly knocking and the trigger information was not in the record. The other resident’s care plan also lacked PTSD trigger information, and staff confirmed no trauma-informed interventions were documented.
PRN morphine was administered to a cognitively intact resident with paraplegia and wounds even when the documented pain rating was zero. The MAR showed multiple PRN doses, but the progress notes contained no additional assessment or justification for those administrations, and the CMA stated she could give pain meds without pain assessment or nursing oversight.
A resident with diabetes and multiple missing teeth reported tooth pain and difficulty chewing, but the request for an emergent dental appt was not handled timely. Staff interviews showed the concern was not consistently known or assessed, and the DNS acknowledged the resident’s request to see a dentist was not timely.
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.
Missed Eye Medication Doses Not Communicated to Nursing
Penalty
Summary
The facility failed to follow physician orders for Resident 6’s erythromycin ophthalmic ointment, which had been ordered on 2/12/26 to be applied in the left eye five times a day. Resident 6 was admitted with diagnoses including end stage renal disease, unspecified conjunctivitis, perforated corneal ulcer, and dependence on renal dialysis. The 2/8/26 MDS documented a medically complex condition including a perforated corneal ulcer in the right eye and conjunctivitis with bacterial agents, and the care plan initiated on 2/12/26 identified the resident as being at risk for complications related to a bilateral eye infection. The 2/2026 MAR showed multiple missed doses of the eye medication on 2/16/26, 2/17/26, 2/18/26, 2/23/26, 2/25/26, and 2/27/26, with documentation that the medication was not given because the resident was at dialysis or absent from the home. There was no documented evidence that the provider was notified about the missed antibiotic eye medication. The resident stated on 5/19/26 that the eyedrops were not received as ordered. Staff interviews indicated the CMAs documented the resident as out of the facility but did not communicate the missed medication to nursing staff, and the LPN and RNCM stated the CMAs should have notified the nurse so the provider could be contacted.
Dishwasher Not at Sanitizing Temperature and Undated Food Found in Resident Refrigerator
Penalty
Summary
The facility failed to ensure the dishwasher reached the minimum temperature required for sanitizing dishes and utensils. The dishwashing policy stated dishes should not be run until the machine reached the proper temperature and that temperatures should be checked and logged. On 2/11/26, the dishwasher temperature log was blank, and the machine’s gauge was observed at 110*F while a dietary aide was rinsing dirty dishes and loading them onto racks. The aide stated the machine was supposed to be at 120*F, and the log for that day was blank. During the observation, the dishwasher remained at 110*F while the dietary aide completed three loads of dishes and prepared a fourth load. A dietary director later confirmed the machine was a low temperature dishwasher and required at least 120*F for dishes and utensils to be considered sanitized. Additional checks showed the water temperature at 111*F and then 118*F, and the dietary director confirmed the dishwasher was not at the temperature needed for proper sanitization. The administrator stated he expected the dishwasher to be at the appropriate level for dishes and utensils to be sanitized and that staff should inform management immediately when the temperature was below the proper level. The facility also failed to ensure food in the resident refrigerator was labeled and stored to minimize spoilage and cross contamination. A resident food policy required refrigerated food from outside sources to be stored with the date received, product name, resident name, and room number, and unlabeled or undated food was to be discarded. The resident refrigerator contained a bag with a resident’s name and room number but no date, and later contained undated watermelon, cantaloupe, honey dew melon in liquid, an undated rotisserie chicken, and two undated slices of processed cheese. Staff gave conflicting statements about who was responsible for labeling and discarding resident food, while the dietary director and administrator stated dietary staff, CNAs, and housekeeping were expected to work together to remove unlabeled, expired, or food stored for three days.
Late and Incomplete MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive MDS assessments within the required timeframe for 3 of 26 sampled residents. Resident 66, admitted in 1/2021 with a diagnosis of encounter for orthopedic aftercare following surgical amputation, had a 1/6/26 Annual MDS Assessment that remained listed as in progress in the health record and was not signed or submitted by the survey exit date. On 2/13/26, the RN MDS Coordinator acknowledged the assessment was not completed within 14 days of the ARD and stated it was partially completed and not ready to be submitted. Resident 30, admitted in 5/2024 with diagnoses including heart failure, had a 1/15/26 re-admission admission MDS that assessed the resident as cognitively intact with little to no interest in doing things. The Activities CAA summary only addressed acclimation to the facility and encouragement to participate in activity programming, with no additional documentation of assessment for the resident’s reasons for little to no interest in recreational, diversional, or leisure activities. The Activity Director stated she did not complete or contribute information for the resident’s leisure and recreational activity preferences, and the DNS expected the triggered Activities CAA to fully assess the resident’s activity needs and preferences. Resident 62, admitted with diagnoses including third degree burns, had a 2/1/26 admission MDS that was completed and signed on 2/10/26, which was two days past the 14-day completion timeframe, and the LPN Resident Care Manager confirmed the late completion.
Delayed Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete Quarterly MDS assessments within the required timeframe for 7 of 8 sampled residents reviewed for resident assessment. The report states that these assessments were required to be updated at least once every 3 months, but several were still listed as in progress or were submitted well after the Assessment Review Date (ARD). Surveyors determined that the delayed or incomplete assessments placed residents at risk for unassessed needs. Resident 12, admitted with pneumonia, had a 1/6/26 Quarterly MDS that remained in progress and was not completed or signed by the survey exit date. Resident 15, admitted with multiple rib fractures, also had a Quarterly MDS that remained in progress and was not completed or signed by the survey exit date. Resident 26, admitted with combined systolic and diastolic heart failure, had a 12/16/25 Quarterly MDS submitted 58 days after the ARD. Resident 45, admitted with ataxic gait, had a 12/17/25 Quarterly MDS still in progress at exit. Resident 51, admitted with hemiplegia and hemiparesis following a stroke, had a 1/6/26 Quarterly MDS still in progress at exit. Resident 67, admitted with dementia, had a 12/23/25 Quarterly MDS still in progress at exit, and Resident 80, admitted with metabolic encephalopathy, had a 1/6/26 Quarterly MDS still in progress at exit. The RN MDS Coordinator acknowledged that the assessments were not completed within 14 days of the ARD and stated that some sections were still unfinished, additional data was still needed, or she did not know when the assessments would be ready to submit. The Administrator acknowledged the assessments were not completed timely and stated he expected all residents' MDS assessments to be completed timely because they were important for developing and maintaining resident-centered care plans.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide resident-centered activities for 5 of 5 sampled residents reviewed for activities, including residents with cognitive intactness and documented activity preferences. The report states that the facility’s activities policy required programs designed to meet each resident’s interests and support physical, mental, and psychosocial wellbeing, and that activities were not limited to formal programs provided only by activities staff. The deficiency was identified through interviews, observations, and record review showing that residents were not consistently informed of, invited to, or provided with activities aligned with their preferences. Resident 20 was admitted with blindness in both eyes and dysphagia following a cerebral infarction. The resident’s MDS showed a BIMS score of 15 and the resident required extensive assistance with all ADLs, including always needing help reading written materials. The activity profile identified music and going outside for fresh air as very important, and group activities as somewhat important. The care plan directed staff to encourage attendance and provide assistance as needed, but the resident stated not knowing the facility had activities and not being invited. The resident was not informed of music and ice cream, a popcorn social, Bingo, or an outing, and stated a desire to attend Bingo and the outing if aware of them. Staff stated activities were announced over the overhead speaker and that the resident was typically asleep, while the activity director acknowledged not following up with the resident and that the independent activity materials provided were inappropriate for a visually impaired resident. Resident 2, Resident 3, Resident 30, and Resident 60 each had MDS-documented preferences such as music, pets, going outside, reading materials, news, religion, and group activities, and each was cognitively intact. Resident 2 stated being bored most of the time, with little interaction or engagement in activities, and the Kardex contained no activity interests or preferences. Resident 3 stated being often bored, missing the book cart and bookshelf, and finding the activity offerings unengaging; the Kardex also lacked activity preferences. Resident 30 stated being bored at times and upset that the television remote did not work consistently, while staff were unaware of the remote issue and the Kardex lacked activity preferences. Resident 60 stated being extremely bored, relying on a cell phone for entertainment, and spending most time in the room with no working television; staff were unaware of the broken television and the Kardex lacked activity preferences. The administrator stated he expected all residents to have individual activity programs to meet their interests through both group and individual activities.
Activities Program Not Directed by a Qualified Professional
Penalty
Summary
The facility failed to provide a qualified professional to direct the activities program for 1 of 1 facility reviewed for activities. On 2/12/26 at 3:15 PM, Staff 9, identified as the Activities Director, stated she had recently been promoted to the role and was not aware of any certifications, trainings, or qualifications required for the position. Staff 9 also confirmed that she was the person who planned both group and individual activities for residents. On 2/13/26 at 8:13 AM, Staff 1, the Administrator, confirmed that Staff 9 had served as Activities Director since 12/2025 and did not have the appropriate certifications, trainings, or qualifications for the role.
Improperly Contained Garbage and Overflowing Dumpsters
Penalty
Summary
The facility failed to ensure waste was properly contained in dumpsters and that garbage storage areas were maintained in a sanitary condition for 1 of 1 garbage area reviewed for kitchen sanitation. On 2/9/26 at 9:24 AM, the dumpsters were observed to be very full and the doors did not close to enclose the trash. On 2/10/26 at 9:18 AM, the dumpsters were again observed to be very full with trash overflowing from the top, with two inside out gloves on the concrete near the dumpsters and one large trash bag placed in front of them. On 2/10/26 at 3:30 PM, the dumpsters remained very full with trash overflowing from the top, four large bags were in front of the dumpsters, and miscellaneous trash items were observed on the ground around the area. On 2/11/26 at 5:00 AM, the dumpsters were still very full with trash overflowing from the top, more than four large bags were placed in front of them, and miscellaneous trash items including inside out gloves were observed on the ground. Staff stated the dumpsters were shared by all employees, garbage was supposed to be collected six times per week Monday through Saturday, and the garbage company was also supposed to pick up the bags off the ground. The Maintenance Director stated he was not sure what happened on 2/9/26 and 2/10/26, and the Administrator stated he expected garbage to be contained in the receptacles and off the ground and for staff to notify management when the dumpsters became too full.
Failure to Perform Hand Hygiene for Staff and Residents
Penalty
Summary
The facility failed to ensure proper hand hygiene was completed for one sampled employee and three sampled residents reviewed for infection prevention and control practices. The 8/1/24 Hand Hygiene policy and procedure required hand hygiene before and after assisting a resident with personal care, after handling soiled or used linens, before applying gloves, and after removing gloves. On 2/10/26 at 9:09 AM, Staff 27, a CNA, was observed wearing gloves while providing care to Resident 8, who was on contact precautions. The care included touching the resident’s gown, legs, bedding, and combing the resident’s hair. Staff 27 then placed the resident’s linens into a bag, removed the gloves, and exited the room using the gloves to carry the bag. Staff 27 was observed continuing down the hall with the dirty gloves in hand, dropping them into a garbage can, and then picking up clean gloves and starting to put them on to enter another room, without performing hand hygiene at any point. During a 2/11/26 Residents Council meeting, residents expressed concern that they were not offered hand hygiene during dining room meal services. During a dining room observation from 11:33 AM to 12:00 PM on 2/11/26, no hand hygiene was offered to residents prior to lunch. At 12:01 PM, Resident 2, Resident 28, and Resident 80 were observed eating lunch in the dining room and stated they were not offered hand hygiene before the meal and would have liked clean hands to eat with. Staff 18, a CNA, stated residents usually washed their hands in the morning and were not offered hand hygiene before lunch unless they requested it. Staff 2, the DNS, stated she would expect residents to be offered hand hygiene prior to eating a meal in the dining room.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure residents were assessed for self-administration of medications for 2 of 5 sampled residents reviewed for accidents. The facility’s policy stated that the Resident Care Manager evaluates a resident’s ability to self-administer medications using a Self Administration Evaluation form, that no medications are stored at bedside or self-administered until the evaluation is complete, and that a physician order is obtained identifying the specific medications the resident may self-administer. In the clinical record for one resident admitted with a fracture of the neck of the left femur and with a BIMS score of 15, no self-administration assessment was completed for Senna and Tums. Observations showed a Tums tablet and a Senna pill in a small plastic cup on the bedside table, and the resident stated staff had given the Senna but the resident did not want to take it and had put it back in the cup, and had also purchased the Tums but changed their mind about taking it. For the second resident, admitted with end stage renal disease, a physician order included guaifenesin to be administered by a clinician as needed for coughing. Observations found three medication containers at the bedside table and no lock box in the room, and the resident stated the medications were there for a cough and that other residents had asked to receive doses on multiple occasions. The record showed no self-administration assessment had been completed for any medications. Staff later confirmed that Musinex, Musinex PM, and two saline nasal rinses were in the room and should not have been there because the resident was not safe to self-administer those medications.
Resident Privacy Breach in Council Meeting
Penalty
Summary
The facility failed to ensure a resident’s right to privacy was honored for 1 of 2 sampled residents reviewed for privacy. Resident 64 was admitted in 2025 with diagnoses including heart failure, and the 8/15/25 MDS assessed the resident as cognitively intact. Review of the 11/2025 Resident Council meeting minutes showed a concern about “too much into personal business,” and the 11/18/25 written response from the Social Services Director stated that Resident 64 was upset because a call had been placed to APS regarding misappropriation of funds. Staff 9, the Activity Director, confirmed she assisted with Resident Council meetings and read the written responses from the meeting minutes out loud exactly as written, and she confirmed Resident 64’s name was included in the minutes. Staff 8 confirmed she documented Resident 64’s name in the response and stated she was not aware the responses would be read aloud or that residents would have access to read them. Resident 64 stated being at the Resident Council meeting and feeling angry that the resident’s name was read out loud to everyone about the facility calling APS.
Failure to Provide Appropriate Foot Care
Penalty
Summary
The facility failed to provide appropriate foot care for two residents. One resident, who was admitted with diabetes and had a BIMS score of 15, had physician orders for weekly fingernail and toenail checks on bath days and nail trimming as needed. Although the resident was scheduled for showers twice weekly and the MAR showed nail care was completed on one shower day, the resident was observed without shoes with a red, swollen foot, white substance around the foot, and two yellow, overgrown toenails curved toward the bottom of the foot. The resident stated staff did not assess the foot or perform nail trimming, and later stated staff did not offer to cut the toenails despite allowing assistance during showers. Staff reported that nail care was expected for residents with diabetes, but the assigned LPN stated the resident refused weekly skin checks and nail care and did not report the refusals to the RNCM. A second resident, admitted with peripheral vascular disease and with intact cognition, had a care plan stating the resident was seen by podiatry for routine toenail care as needed, but no documentation was found showing podiatry care had been provided in the prior year. The resident stated the toenails were so long that there was concern about breakage and infection, and staff confirmed the facility’s mobile podiatrist no longer accepted the resident’s insurance plan. When the resident’s shoes and socks were removed, both feet were observed with thick, yellowed, very long toenails extending about one-half inch past the toes. The DNS acknowledged that podiatry services had not been provided per the care plan.
Failure to Assess and Document Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to ensure trauma-informed care was assessed and documented for two residents with diagnoses including PTSD and anxiety. One resident was admitted with PTSD and anxiety, had a BIMS score of 15 indicating cognitive intactness, and had a care plan that identified PTSD but did not include resident-specific triggers or prevention techniques. Records reviewed from admission through the survey date showed no trauma-informed care assessment had been completed to identify triggers, prevention techniques, or interventions to use if PTSD was triggered. The resident stated that loud sudden noises, including staff loudly knocking on the door, triggered a startled response and night terrors, and said staff had been told to lightly tap before entering. Despite this, a CNA was observed loudly knocking on the resident’s door, and staff later confirmed the resident did not like loud knocking but that this information was not documented. For the second resident, the record showed a trauma screen had been completed previously but no other trauma screen was found, and the care plan contained no PTSD trigger information or interventions. Staff confirmed there were no care plan interventions for possible retraumatization and stated they were unaware of the need to assess and document trauma-informed care until shortly before the survey.
PRN Morphine Given Without Supporting Pain Assessment
Penalty
Summary
Ensure each resident's drug regimen was free from unnecessary drugs was not met when the facility failed to ensure adequate indications for medication use for one sampled resident. The resident was admitted in 1/2026 with diagnoses including paraplegia and wounds, and the care plan identified that the resident's pain would be relieved to a tolerable level as indicated by the resident. A physician's order dated 1/11/26 was in place for Morphine Sulfate 10 MG/5 ML every six hours as needed for pain. The admission MDS dated 1/16/26 showed a BIMS score of 14, indicating the resident was cognitively intact. The MARs for 1/2026 and 2/2026 showed a CMA administered PRN morphine seven times when the pain rating was zero, and the progress notes contained no additional assessment or justification for those administrations. The CMA stated she was able to administer pain medications with no pain assessment or nursing oversight and did not recall giving PRN morphine to the resident with a pain rating of zero. The RNCM stated the resident identified a pain level of four or five as tolerable, that the resident was always in pain and would never be at a pain rating of zero, and that a pain rating assessment should always be conducted and reported to the licensed nurse when a resident requested pain medication.
Delayed Emergency Dental Care
Penalty
Summary
The facility failed to provide emergency dental services for one sampled resident who was admitted with diagnoses including diabetes. The resident’s care plan indicated the resident had own teeth and needed assistance setting up oral hygiene supplies, and the quarterly MDS indicated a BIMS score of 15 with no dental pain, discomfort, or difficulty chewing at that time. A progress note on 11/21/25 documented that the resident was verbally aggressive with staff and reported a toothache. A progress note on 11/25/25 stated a Social Services Assistant called to arrange an emergent dental appointment, but the clinic instructed her to call back the next day and said an appointment would be scheduled within 48 hours. During interview, the resident stated the resident had no upper teeth, multiple missing lower teeth, had dental pain and discomfort in 11/2025, and was unable to chew food. Staff interviews reflected that emergent dental appointments were generally scheduled quickly, but multiple staff members were unaware of the resident’s dental concerns, and the DNS acknowledged the resident’s request to see a dentist was not timely.
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.
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What surveyors actually found near you
We read the 523 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Portland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rose City Nursing And Rehabilitation | 0.6 mi | ★★★★★ | 1 | 0 |
| Portland Health And Rehabilitation | 0.6 mi | ★★★★★ | 21 | 0 |
| Glisan Post Acute | 1 mi | ★★★★★ | 11 | 0 |
| Gateway Care And Retirement | 1 mi | ★★★★★ | 0 | 0 |
| Marquis Mill Park | 1.4 mi | ★★★★★ | 13 | 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.