Stanley Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Milwaukie, Oregon.
- Location
- 12045 Se Stanley Avenue, Milwaukie, Oregon 97222
- CMS Provider Number
- 385270
- Inspections on file
- 23
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Stanley Post Acute during CMS and state inspections, most recent first.
A dependent resident with diabetes and urinary incontinence, care planned as requiring two-person assistance for all bed mobility and toileting, was being changed in bed by two CNAs when one left the room to obtain barrier cream, leaving the resident on their side with only one CNA present. While the remaining CNA was at the sink wetting a washcloth, the resident stated they were falling and was subsequently found on the floor by the returning CNA and an LPN. The resident was transferred to the hospital and later found to have bilateral femur fractures requiring surgery. Multiple staff, including CNAs, an RN, an LPN care manager, and the DNS, confirmed that the resident was fully dependent, could not roll independently, and should have had two staff present throughout care or been repositioned onto their back before any staff left.
Staff failed to properly disinfect reusable medical equipment, including vital sign equipment and a community-use glucometer, between resident uses, and used personal care wipes instead of EPA-approved disinfectant wipes. An LPN did not clean a glucometer between residents until prompted by a surveyor. During meal service, a nursing assistant delivered food trays to multiple rooms and a family member without performing hand hygiene between rooms. These lapses were confirmed by supervisory staff and placed residents at risk for cross-contamination.
A resident with insomnia and depression was prescribed quetiapine fumarate, with the dosage increased over time. There was no documentation that the resident was informed of the risks and benefits of this antipsychotic medication, as confirmed by the DNS.
Two residents with chronic conditions did not have their advance directives available in their clinical records, despite care plans indicating these documents should be present and honored. Staff were unable to locate the advance directives and confused POLST forms with advance directives, confirming the documents were missing from the records.
A resident with multiple sclerosis and lower extremity ROM impairment did not receive prescribed passive ROM exercises as outlined in their care plan. Documentation and staff interviews confirmed that restorative services were not consistently provided, and CNAs were unaware or did not perform the required exercises after the facility transitioned responsibility from a designated restorative aide.
An LPN was observed preparing insulin glargine for a resident using a vial that did not have an open date labeled, despite manufacturer instructions requiring the medication to be discarded 28 days after opening. The LPN confirmed the vial was open without the necessary labeling, resulting in a failure to follow proper medication labeling protocols.
A resident with blindness did not receive a new lower denture as ordered by a physician, despite attending a dental appointment. The resident reported not receiving the denture and was unsure why. Both social services and the LPN resident care manager were unaware of the order and confirmed that no follow-up had occurred after the appointment.
A resident with multiple sclerosis and overactive bladder, who required two-person assistance for toileting, was assisted by only one CNA, resulting in a fall from bed. The CNA disregarded the care plan and provided care alone, and facility leadership confirmed the care plan was not followed.
A facility failed to provide a complete discharge summary for a resident with hip fracture and CHF, omitting key details like diagnosis, treatment, and home health agency information. A complaint revealed the resident was not referred to their usual home health agency, disrupting continuity of care. The Social Services Director acknowledged the expectation for comprehensive discharge summaries and typical referral practices.
A facility failed to follow physician orders for a resident with ESRD and a clavicle fracture, resulting in missed doses of Gabapentin and Sodium Zirconium Cyclosilicate. The resident's care plan required these medications for pain and hyperkalemia management, but the MAR showed omissions without explanation. The facility's administration was notified but provided no further information.
The facility failed to comprehensively assess eight residents for medications, pressure ulcers, ADLs, pain, and nutrition. Incomplete CAAs lacked descriptions of problems, causes, contributing factors, and effectiveness of treatments. Staff 16's remote work and Staff 2's unfamiliarity with the CAA process contributed to the deficiencies, which were acknowledged by the facility's administration.
The facility failed to ensure that CNAs received annual performance reviews. A review of personnel records revealed that four CNAs, hired between 2016 and 2022, did not have any annual performance reviews completed. The Administrator confirmed that it was his expectation for annual performance reviews to be conducted, but acknowledged that they were not completed for these staff members.
A resident with end-stage renal disease and depression reported feeling embarrassed and berated after a staff member made a derogatory comment during a bowel incident. Multiple staff members corroborated the event, revealing a failure to maintain a respectful and dignified environment.
The facility failed to assess the self-administration of medication for two residents, placing them at risk for unsafe medication administration. One resident self-administered eye drops without an assessment, while another resident self-administered a nasal spray not included in their self-administration assessment.
The facility failed to ensure resident personal property was identified and accessible, leading to a resident being without appropriate clothing and another experiencing delays in reimbursement for missing and damaged items.
The facility failed to ensure a written summary of a baseline care plan was reviewed and provided to residents within 48 hours of admission for two residents. One resident with paralysis and osteoporosis and another with heart failure and chronic kidney disease did not receive their baseline care plans, as confirmed by staff.
The facility failed to follow physician orders and provide timely bowel medication for a resident, leading to extended periods without a bowel movement. Despite having a bowel care protocol in place, the staff did not consistently implement it, resulting in the resident experiencing constipation for six days on two separate occasions.
The facility failed to provide appropriate foot care for three residents with significant medical conditions, resulting in overgrown, thick, and discolored toenails. Despite physician orders and resident requests, staff did not adequately address the nail care needs, leading to severe toenail conditions.
The facility failed to prevent smoking-related accidents for a resident with a history of unsafe smoking behaviors. Despite multiple incidents and the removal of smoking materials, the resident continued to possess and use smoking paraphernalia in their room, and the care plan lacked adequate interventions for safe storage and supervision.
A resident with acute and chronic respiratory failure was found using an oxygen concentrator set at three liters instead of the prescribed two liters. The external filter of the concentrator was also covered in dust. Staff acknowledged the discrepancy and the unclean condition of the equipment.
A resident with severe pain did not receive scheduled doses of Percocet due to an expired prescription and delays in obtaining a new one. Staff acknowledged the oversight in the medication reorder process, resulting in the resident experiencing significant pain and discomfort.
The facility failed to provide person-centered approaches to behavioral symptoms for a resident diagnosed with PTSD. Despite a psychiatric consultation recommending continued psychotherapy, there was no follow-up treatment or care plan interventions documented. Staff observations and interviews confirmed the resident exhibited PTSD-related behaviors and expressed a willingness for continued mental health treatment, but no actions were taken to address these needs.
The facility failed to ensure proper labeling of biologicals in one of the medication rooms. A vial of lidocaine solution was found opened without an open date label, which was acknowledged by the DNS. This is against CDC guidelines for multi-dose vials.
The facility failed to protect resident-identifiable information and maintain accurate medical records for two residents. Resident information was found in an unsecured garbage bag, and the diabetic administration record did not reflect documented interventions for a resident with Type 1 Diabetes.
Failure to Follow Two-Person Assistance Care Plan Resulting in Fall and Fractures
Penalty
Summary
The deficiency involves the facility’s failure to follow the care plan interventions requiring two-person assistance for bed mobility and incontinence care for a dependent resident, resulting in a fall with bilateral femur fractures. The resident, admitted in 2015 with diabetes and urinary incontinence, had an MDS assessment dated 1/9/26 and a care plan indicating dependence on staff for ADLs, including bed mobility and toileting, and specifically required two-person assistance. On 2/7/26, during incontinence care, two CNAs were assisting the resident, who was positioned on their side. One CNA (Staff 5) left the room to request barrier cream from an LPN (Staff 3), leaving the other CNA (Staff 4) alone with the resident. While Staff 5 was outside the room, Staff 4 obtained and wet a washcloth at the sink with the resident still on their side. The resident then yelled that they were rolling, and Staff 4 called for help. Staff 5 and Staff 3 entered the room and found the resident on the floor. Progress notes documented that the resident was transferred to the hospital after the witnessed fall and that the hospital later reported the resident required surgery on both legs due to bilateral femur fractures. The fall report, initiated on 2/7/26 and updated on 2/9/26, confirmed the sequence of events and the resulting injuries. In interviews, multiple staff members, including CNAs, an RN, an LPN/Care Manager, and the DNS, consistently stated that the resident was fully dependent, unable to perform bed mobility, and required two-person assistance for all bed mobility and incontinence care. They further stated that for a two-person dependent resident, both staff must remain with the resident for the duration of care, and the resident should not be left on their side unattended but should be repositioned onto their back before any staff leave the room. Staff 4 acknowledged in her statement that she was the only person in the room when the resident fell and that the resident should have been rolled onto their back before she left.
Failure to Disinfect Reusable Equipment and Perform Hand Hygiene
Penalty
Summary
Facility staff failed to follow appropriate disinfection practices for reusable medical equipment, including vital sign equipment and community-use glucometers. On multiple occasions, a CNA was observed moving a rolling vitals cart with reusable equipment from one resident room to another without cleaning the equipment between uses. When questioned, the CNA used personal care wipes instead of the required EPA-approved disinfectant wipes, stating that CNAs no longer had access to the proper wipes. The Director of Nursing Services confirmed that only EPA-approved Super Sani-Cloth wipes were acceptable for disinfecting reusable equipment, and personal care wipes did not contain the necessary germicide. Additionally, an LPN was observed using a community-use glucometer on one resident and then preparing to use it on another without cleaning it in between, only disinfecting it after intervention by a surveyor. The LPN acknowledged forgetting to clean the glucometer, and the DNS reiterated the expectation to use EPA-approved wipes and observe the required dwell time between uses. During meal service, a nursing assistant was observed delivering food trays to multiple resident rooms and to a family member without performing hand hygiene between rooms. The staff member admitted to not performing hand hygiene after leaving resident rooms during meal service. The LPN Resident Care Manager confirmed that staff were expected to perform hand hygiene after leaving each resident room during meal service. These failures were observed on one of four halls reviewed for infection control and meal service, and involved at least one sampled resident during medication pass.
Failure to Inform Resident of Psychotropic Medication Risks and Benefits
Penalty
Summary
The facility failed to inform a resident of the risks and benefits associated with the use of a psychotropic medication. The resident, who was admitted with diagnoses of insomnia and depression, was prescribed quetiapine fumarate initially at 25mg for insomnia, which was later increased to 50mg for depression. Review of the resident's medical record showed no documentation that the resident was informed about the risks and benefits of quetiapine fumarate. This was confirmed by the Director of Nursing Services, who acknowledged the absence of such evidence in the medical record.
Failure to Maintain Advance Directives in Resident Records
Penalty
Summary
The facility failed to ensure that advance directives were available in the clinical records for two of four sampled residents. For one resident with a history of diabetes, the care plan indicated the presence of an advance directive and a medical power of attorney, but neither document was found in the medical record. The resident confirmed having completed an advance directive with family, and the care plan required that the directive be honored and kept on file. However, staff were unable to locate the document and were unclear about the distinction between a POLST and an advance directive, using the terms interchangeably. Similarly, another resident with multiple sclerosis had a care plan stating an advance directive was in place and should be honored, but the document was not present in the clinical record. The resident reported completing an advance directive while at the facility. Staff again referenced a POLST as being on file and demonstrated a lack of understanding regarding the difference between a POLST and an advance directive. In both cases, the absence of the required documentation in the medical record was confirmed by staff.
Failure to Provide Prescribed Restorative ROM Services
Penalty
Summary
A resident with multiple sclerosis, admitted in August 2022, was identified as requiring passive range of motion (ROM) exercises for both lower extremities to address impairments and prevent further decline. The resident's care plan, last revised in August 2025, included a restorative nursing program specifying bilateral knee and right hip passive ROM exercises. However, review of the resident's ROM Program Task tracking form and the restorative nursing services binder from early August to early September 2025 revealed no documentation that these restorative services were provided. The most recent Minimum Data Set (MDS) assessment also indicated that the resident did not receive passive ROM during the look-back period, despite being cognitively intact and having documented ROM impairment. Interviews with the resident and multiple staff members confirmed that the resident was not receiving the prescribed ROM exercises. The resident reported that staff no longer provided ROM exercises for their legs. Certified Nursing Assistants (CNAs) interviewed were either unaware of the resident's need for restorative services or confirmed they had not provided the exercises. The LPN Resident Care Manager acknowledged the resident's restorative program and stated that, following the absence of a designated restorative aide, CNAs were responsible for delivering these services, which were expected to be provided according to the care plan.
Insulin Vial Lacked Required Open Date Label
Penalty
Summary
A deficiency was identified when, during observation, an LPN prepared insulin glargine for a resident using a vial that did not have an open date labeled. The manufacturer's instructions for insulin glargine require the medication to be discarded 28 days after opening, making the open date essential for proper medication management. The LPN acknowledged that the insulin vial was open but lacked the required open date, indicating a failure to ensure proper labeling of biologicals as required by professional standards.
Failure to Assist Resident in Obtaining Ordered Denture
Penalty
Summary
The facility failed to assist a resident with obtaining a new lower denture as ordered by the physician. The resident, who was blind and had no dental concerns noted at admission, had a physician's order and progress note indicating the need for a new bottom denture. However, there was no documentation in the clinical record regarding any follow-up or completion of this order. The resident reported having had a dental appointment two months prior and was expecting to receive the denture but had not received it and was unaware of the reason. Staff responsible for social services and resident care management were both unaware of the order and acknowledged that no follow-up had been completed since the dental appointment.
Failure to Follow Two-Person Assistance Care Plan During Toileting
Penalty
Summary
Staff failed to follow the care plan for a resident with multiple sclerosis and overactive bladder, who was cognitively intact but dependent on others for toilet hygiene. The resident's care plan required two-person assistance for toileting. However, during an incident, an agency CNA provided toileting care alone without a second staff member, contrary to the care plan. As a result, the resident fell out of bed while being assisted. The resident reported that the CNA stated she could provide care without assistance, and facility leadership acknowledged that the care plan was not followed at the time of the fall.
Incomplete Discharge Summary and Referral Error
Penalty
Summary
The facility failed to complete a comprehensive discharge summary for a resident who was discharged home. The discharge summary lacked essential information such as a nursing or physician recapitulation of the resident's diagnosis, course of illness or treatment at the facility, pertinent home health agency or contact information, prognosis, or condition on discharge. This deficiency was identified during a review of the discharge summary dated 6/25/24 for a resident admitted with diagnoses including hip fracture and congestive heart failure. A public complaint was received alleging that the resident was not referred to their long-standing home health agency, resulting in a lack of continuity of care. The Social Services Director confirmed that it was expected for discharge summaries to include such information and that typically, residents were referred to their previous home health agency unless services could not be resumed.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to adhere to physician orders for a resident diagnosed with End Stage Renal Disease (ESRD) and a clavicle fracture, who was admitted in August 2024. The resident's care plan included medications for pain management and ESRD, with dialysis scheduled twice weekly. Physician orders specified the administration of Gabapentin, 100 mg capsule three times daily, and Sodium Zirconium Cyclosilicate, one packet daily on non-dialysis days to manage hyperkalemia. However, a review of the resident's medication administration record (MAR) for September 2024 revealed that Sodium Zirconium Cyclosilicate was not administered on two occasions, and Gabapentin was missed on three consecutive days. Progress notes from the period did not provide any explanation for these omissions. The facility's administrator and director of nursing services were informed of these findings but did not offer additional information.
Incomplete Comprehensive Assessments for Multiple Residents
Penalty
Summary
The facility failed to comprehensively assess eight residents for medications, pressure ulcers, ADLs, pain, and nutrition. Resident 57, admitted with chronic heart failure and diabetes, had an incomplete Psychotropic Drug Use CAA that lacked a description of the problem, causes, contributing factors, and effectiveness of the medication. Staff 16, responsible for completing the MDS assessment and CAAs, worked remotely and reviewed electronic medical records, but the CAA was not comprehensive. Staff 2, the DNS, was unfamiliar with the CAA process, and both Staff 1 (Administrator) and Staff 2 acknowledged the deficiency. Resident 55, admitted with a Stage 3 pressure ulcer, had a Pressure Ulcer CAA that did not include a description of the problem, causes, contributing factors, alternatives discussed, or an overall analysis of the pressure ulcer. Similar issues were found with Resident 36, who had arthritis and polyneuropathy, and received pain medication. The Pain CAA did not describe how the resident displayed pain symptoms or the effectiveness of the medications and other interventions. Staff 16 completed the assessments remotely, and Staff 2 was unfamiliar with the CAA process, leading to incomplete assessments. Other residents, including Resident 114 with end-stage renal disease and depression, Resident 25 with falls and chronic pain syndrome, Resident 32 with cellulitis and diabetes, Resident 26 with glaucoma and depression, and Resident 52 with depression, also had incomplete CAAs. These CAAs lacked descriptions of problems, causes, contributing factors, and effectiveness of treatments. Staff 16's remote work and Staff 2's unfamiliarity with the CAA process contributed to the deficiencies, which were acknowledged by the facility's administration.
Failure to Conduct Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received annual performance reviews, as required. During a review of personnel records with the Human Resource Director, it was found that four CNAs, hired between 2016 and 2022, did not have any annual performance reviews completed. The Administrator confirmed that it was his expectation for annual performance reviews to be conducted, but acknowledged that they were not completed for these staff members.
Failure to Ensure Resident Dignity
Penalty
Summary
The facility failed to ensure a resident was treated in a dignified manner, as evidenced by an incident involving Resident 114. Resident 114, who had diagnoses including end-stage renal disease and depression, reported that during the night shift, a female staff member entered the room after the resident had a bowel movement in bed and made a derogatory comment, saying, 'Oh, you shit the bed.' This incident was corroborated by multiple staff members who recalled the event and the staff member's comments. Resident 114 felt embarrassed and berated by the staff member's remarks. The investigation revealed that Staff 26, who was identified as the staff member involved, denied making the derogatory comment but admitted to assisting in cleaning up the resident. Other staff members, including Staff 21, confirmed that Staff 26 had made similar comments at the nurses' station. Despite the denial, the investigation concluded that the staff member's behavior was inappropriate and not in line with treating residents with dignity. The incident highlighted a failure in maintaining a respectful and dignified environment for the resident.
Failure to Assess Self-Administration of Medication
Penalty
Summary
The facility failed to assess the self-administration of medication for two residents, placing them at risk for unsafe medication administration. Resident 8, admitted with diagnoses including a stroke and heart disease, had a physician order for Artificial Tears ophthalmic solution. Despite being cognitively intact with a BIMS score of 14, there was no evidence of a self-administration assessment in the clinical record. Observations revealed the resident had the eye drops on their bedside table and self-administered them, contrary to staff statements that the resident required assistance. The Resident Care Manager was unaware of the eye drops' presence and removed them, acknowledging that a self-medication assessment was necessary but not completed. Resident 26, admitted with paraplegia and cognitively intact, kept a prescription medication, ipratropium bromide nasal spray, at their bedside in a locked box. Although the resident's care plan indicated self-administration of certain medications, the specific nasal spray was not included in the self-administration assessment. Staff confirmed the resident self-administered the nasal spray and reported its use to the charge nurse, who documented the administration. However, the Resident Care Manager confirmed that the resident was not assessed to self-administer the nasal spray, indicating a lapse in following the facility's self-administration policy.
Failure to Manage and Respect Resident Personal Property
Penalty
Summary
The facility failed to ensure resident personal property was identified upon admission and that clothing was retained and accessible for two residents. Resident 57, admitted with diagnoses including chronic heart failure and diabetes, was observed multiple times without appropriate clothing. Despite the resident's requests to be dressed in their own clothes, staff were unable to locate the items, which were not labeled as required by the facility's policy. The resident's inventory record was incomplete, and no missing item report was filed, indicating a failure to follow the established procedures for managing personal belongings. Resident 20, admitted with diagnoses including depression and anxiety, reported missing and damaged personal property through grievance forms. Although the grievances were acknowledged and reimbursement was approved by the administrator, the reimbursement was not issued in a timely manner. The delay in addressing the resident's grievances further highlights the facility's failure to respect and manage residents' personal possessions as per their policy.
Failure to Provide Baseline Care Plans
Penalty
Summary
The facility failed to ensure a written summary of a baseline care plan was reviewed and provided to residents within 48 hours of admission for two of three sampled residents. Resident 4, admitted in 2022 with diagnoses including paralysis of the left side and osteoporosis, did not have a baseline care plan reviewed or provided. This was confirmed by Staff 3 (Corporate SSD) on 5/16/24. Similarly, Resident 44, admitted in February 2024 with diagnoses including heart failure and chronic kidney disease, also did not have a baseline care plan reviewed or provided. This was confirmed by Staff 3 on 5/16/24. Both residents were at risk of being uninformed about their plan of care due to this deficiency.
Failure to Follow Bowel Care Protocol
Penalty
Summary
The facility failed to follow physician orders and provide bowel medication in a timely manner for a resident reviewed for medications. The facility's Bowel Care Protocol Policy specified that residents who had not had a bowel movement (BM) for three days should be given Milk of Magnesia (MOM), followed by a Dulcolax suppository if no BM occurred by the next shift, and a Fleets enema if there was still no BM by the following shift. If a resident exceeded four days without a BM, an abdominal assessment was to be completed, and the physician was to be notified for further orders. However, Resident 57 did not have a BM for six days on two separate occasions, and there was no documentation that bowel care was implemented timely or that an abdominal assessment was completed. Resident 57, who was admitted with diagnoses including chronic heart failure and diabetes, had a physician order for polyethylene glycol packet to be administered daily as needed for bowel care. Despite this order, the medication was only administered once and marked as unknown. Interviews with staff revealed that Resident 57 frequently struggled with constipation and was often on the bowel list. Staff acknowledged that the bowel protocol needed to be initiated due to the resident's constipation, but it was not consistently followed. The Director of Nursing Services (DNS) confirmed that staff were expected to implement and adhere to the bowel protocol, including contacting the physician and conducting a bowel assessment if a resident had no BM by day four.
Failure to Provide Appropriate Foot Care
Penalty
Summary
The facility failed to provide appropriate foot care for three residents, all of whom had significant medical conditions requiring careful nail management. Resident 41, a diabetic, had a physician's order for weekly nail checks and trimming as needed. Despite this, the resident's toenails were observed to be long, thick, discolored, and deformed. The resident expressed discomfort and a preference for podiatric care, which had not been scheduled. Staff acknowledged the condition of the toenails but did not adequately address the issue, leading to the resident's toenails becoming severely overgrown and discolored. Resident 57, also diabetic, had similar orders for weekly nail checks and trimming. However, the resident reported that their toenails were long and thick, and observations confirmed that the toenails were overgrown and discolored. Staff admitted to not being sure about the condition of the resident's toenails and failed to ensure that appropriate nail care was provided. The resident's toenails were not treated appropriately, as confirmed by staff during the survey. Resident 26, diagnosed with paraplegia, reported that their toenails were long, thick, and catching on their socks. Despite requesting nail care, the resident's toenails remained untreated. The resident's toenails were observed to be long, thick, fungal, and jagged. Staff acknowledged that toenail care should have been provided on bath days but failed to follow through. The facility had a podiatrist who visited every three months, but the resident had not been seen yet, leaving their toenails in poor condition.
Failure to Prevent Smoking-Related Accidents
Penalty
Summary
The facility failed to ensure interventions were in place to prevent smoking-related accidents for a resident with a history of unsafe smoking behaviors. The resident, who was admitted with diagnoses including right lower extremity cellulitis and diabetes, was found to have triggered a fire alarm by burning papers in their room and was in possession of a torch lighter. Despite multiple incidents of smoking in their room and the removal of smoking materials, the resident's care plan did not include adequate interventions for safe storage of smoking paraphernalia or address previous smoking incidents. Staff interviews revealed inconsistencies in the enforcement of the smoking policy and supervision of the resident. The resident continued to possess and use smoking materials in their room, including a blow torch lighter, which was observed by staff. A smoking safety evaluation completed later indicated the resident was a supervised smoker who was not receptive to supervision and continued to make unsafe smoking choices. The facility's Director of Nursing Services acknowledged the safety concerns and the delay in completing a smoking assessment and updating the care plan.
Failure to Maintain Oxygen Equipment and Administer Correct Oxygen Flow Rate
Penalty
Summary
The facility failed to maintain oxygen equipment and ensure oxygen was administered as ordered for a resident with acute and chronic respiratory failure. The resident, who was cognitively intact, had a physician's order for continuous oxygen at a flow rate of two liters. However, during an observation, the resident was found using an oxygen concentrator set at three liters, and the external filter of the concentrator was covered in dust. The resident was unable to state the prescribed oxygen flow rate. Staff acknowledged the discrepancy in the oxygen flow rate and the unclean condition of the equipment.
Failure to Manage Resident's Pain Medication
Penalty
Summary
The facility failed to ensure a resident's ordered pain medication was available and effectively managed the resident's severe pain. Resident 36, who was admitted with diagnoses including rheumatoid arthritis, a fractured tibia, and polyneuropathy, did not receive her/his scheduled Percocet doses on multiple occasions. The resident's medication administration record (MAR) revealed missed doses, leading to significant pain levels reported by the resident. Observations and interviews confirmed that the resident was in visible pain and discomfort due to the lack of timely medication administration. Staff members acknowledged the issue and indicated that the medication reorder process was not properly followed, resulting in the resident's pain medication running out and not being promptly refilled. On multiple occasions, the resident was observed in pain, and staff confirmed that the resident's pain medication had expired and was not reordered in a timely manner. The resident reported high pain levels and was visibly uncomfortable, which was corroborated by staff observations. The facility's staff, including LPNs, CNAs, and CMAs, acknowledged the oversight in medication management and the delay in obtaining a new prescription. The deficiency was attributed to a failure in the medication reorder process, where CMAs were responsible for ensuring timely refills but did not act promptly, leading to the resident experiencing unrelieved pain for an extended period.
Failure to Provide Person-Centered Behavioral Interventions for Resident with PTSD
Penalty
Summary
The facility failed to provide person-centered approaches to behavioral symptoms for a resident diagnosed with post-traumatic stress disorder (PTSD). Resident 32, admitted with diagnoses including right lower extremity cellulitis and diabetes, did not have a documented mental health diagnosis at the time of admission. However, a psychiatric consultation on 3/22/24 revealed the resident was experiencing labile emotions and cycling through traumatic war memories, with a recommendation for continued psychotherapy treatments. Despite this, there was no follow-up treatment or care plan interventions documented to address the resident's mental health needs after the initial consultation. Observations and interviews with staff indicated that Resident 32 exhibited behaviors such as talking about the war, keeping the curtain drawn, startling easily, and overreacting when startled. The resident expressed a willingness to continue mental health treatment if offered. However, the clinical record review on 5/17/24 confirmed the absence of any follow-up mental health treatment or updated care plan to reflect the resident's mental health needs. Staff acknowledged the lack of follow-up treatment and care plan updates, highlighting a deficiency in addressing the resident's psychosocial well-being.
Improper Labeling of Biologicals
Penalty
Summary
The facility failed to ensure proper labeling of biologicals in one of the two medication rooms reviewed for medication storage. During an observation and interview on 5/20/24 at 12:40 PM, a vial of lidocaine solution was found to be opened without an open date label. This vial was identified as a multiple dose vial. Staff 2 (DNS) acknowledged the vial was opened and not labeled with an open date, which is against the guidelines provided by the CDC for multi-dose vials, which require the date and time to be written on the label when first used and discarded within 28 days of opening.
Failure to Protect Resident Information and Maintain Accurate Medical Records
Penalty
Summary
The facility failed to protect resident-identifiable information and ensure accurate medical records for two residents. Resident-identifiable information, including a resident's name, medication type, prescription number, and physician's name, was found in a clear plastic garbage bag without a lid, located on the side of a nurse treatment cart in a hallway near the front entrance. This information was accessible to anyone in the facility. Staff acknowledged that resident-identifiable information should be placed in a secure confidential shred bin inside the facility, not in any garbage bag. Additionally, the facility failed to maintain accurate medical records for a resident with Type 1 Diabetes. The resident experienced hypoglycemic episodes, but the diabetic administration record did not reflect the interventions documented in the progress notes. For instance, a progress note indicated that the resident's blood glucose level was 61 before breakfast, but this was incorrect. The diabetic administration record also did not show the interventions administered on specific dates, despite the progress notes documenting these actions. Staff confirmed the discrepancies in the records and acknowledged that the diabetic administration record was blank for the dates in question.
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.
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