Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Woodside Post Acute during CMS and state inspections, most recent first.
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 resident with Full Code status was found unresponsive and did not receive timely CPR due to an LPN's belief that the resident was already deceased. The LPN failed to verify code status or initiate a Code Blue, resulting in a delay of 13 to 20 minutes before CPR was started, only after direction from the DNS. This delay was confirmed by multiple staff and constituted a failure to follow emergency response protocols.
The facility did not complete required reference and criminal background checks for three newly hired staff members before they began working, as mandated by its abuse prevention policy. This failure to follow established screening procedures was confirmed by Human Resources and the Administrator.
Staff did not notify the physician when a resident's blood glucose readings exceeded the parameters specified in the physician's order. Despite several instances of elevated CBG levels, documentation and staff interviews confirmed that the physician was not informed due to a misunderstanding of the required notification threshold.
A resident with cognitive impairment and a history of falls was injured when their leg came into contact with a baseboard heater due to the bed being positioned too close. Despite care plan interventions to prevent such incidents, the resident was found with their legs off the bed, resulting in a burn. The facility's failure to maintain a safe distance between the bed and heater contributed to the accident.
A resident with dementia and a history of elopement left the facility unsupervised multiple times due to inadequate supervision and malfunctioning exit doors. Despite being identified as an elopement risk, the resident managed to leave the premises, including an incident where they were found at a nearby convenience store. Staff were inconsistent in their awareness of the resident's risk, and the facility failed to conduct investigations or implement effective care plans to prevent further elopements.
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.
Delayed CPR Initiation for Full Code Resident
Penalty
Summary
The facility failed to timely administer CPR to a resident who was identified as Full Code, resulting in a significant delay of 13 to 20 minutes before lifesaving measures were initiated. The resident, who had a history of hemiparesis and a tracheostomy, was found unresponsive by a CNA, who immediately reported the situation to an LPN. The LPN assessed the resident, noted unresponsiveness and yellowing of the skin, and declared the resident deceased without verifying code status or initiating CPR. The LPN did not call a Code Blue or check the resident's code status at that time. Subsequently, the LPN contacted the DNS for further instructions, and only after being directed to verify code status and start CPR did the LPN begin resuscitation efforts, which occurred 13 to 20 minutes after the initial assessment. During this period, no Code Blue was called, and emergency services were not immediately contacted. Multiple staff interviews confirmed the delay in initiating CPR and the failure to follow established emergency response protocols, including verification of code status and prompt initiation of lifesaving measures for a resident with Full Code status.
Removal Plan
- Re-educating licensed nurses on the process of verifying code status, including POLST or physician orders when residents were observed with no pulse or respirations.
- Reeducated licensed nurses including float and agency nurses on emergency response.
- Medical records conducted audits on all new residents for a signed POLST or physician's order to determine resident's status until substantial compliance was met.
- Audits implemented to ensure proper initiation of emergency CPR services were provided during mock code blue for all shifts with no deficient practice found.
Failure to Complete Required Employee Abuse Screening and Background Checks
Penalty
Summary
The facility failed to implement its own policies and procedures for screening potential employees to prevent abuse, neglect, and theft. Specifically, for three newly hired staff members, reference checks with previous employers were not completed as required by the facility's abuse screening policy. This omission was confirmed by both Human Resources staff and the Administrator during interviews and record reviews. Additionally, criminal background checks for these same three new employees were not initiated until after they had already begun working at the facility, contrary to the policy that requires such checks to be completed prior to employment. The delayed initiation of these background checks was acknowledged by facility leadership, indicating a lapse in adherence to established abuse prevention protocols.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
Facility staff failed to notify the physician when a resident's capillary blood glucose (CBG) levels exceeded the parameters set by the physician's order. The resident, who had diagnoses including diabetes and dementia, had a physician order requiring staff to check CBG three times daily and notify the physician if the CBG was less than 70 or greater than 350. Despite multiple documented instances where the resident's CBG was above 350, there was no evidence in the clinical record that the physician was notified. Interviews with staff revealed a misunderstanding of the notification threshold, with staff believing physician notification was only necessary if the CBG exceeded 450, contrary to the physician's order.
Resident Burned Due to Proximity of Bed to Heater
Penalty
Summary
The facility failed to prevent an accident involving a resident with a traumatic brain injury and moderate cognitive impairment, who was at risk for falls due to immobility. The resident was found with their legs hanging off the bed, with one leg resting on a baseboard heater, resulting in a burn. The care plan for the resident included anticipating and meeting needs, educating and reminding the resident to call for assistance with transfers, and providing verbal cues for assistance. However, the resident was frequently observed trying to get out of bed and moving their legs around, which was not adequately addressed by the facility. On the day of the incident, a CNA found the resident with their legs off the bed and one leg on the heater, causing a burn. The bed was positioned too close to the heater, approximately 1 to 2 feet away, contrary to the expected distance of 3 feet. The staff did not observe any other objects that could have caused the injury, and the heating unit was found to be very warm to the touch. Despite weekly audits of the heating units, the proximity of the bed to the heater was not corrected, leading to the resident's injury.
Resident Elopement Due to Inadequate Supervision and Security
Penalty
Summary
The facility failed to ensure the safety of a resident with a history of elopement, resulting in multiple incidents where the resident left the facility unsupervised. The resident, who had been diagnosed with stroke and dementia, was identified as having poor impulse control and was at risk for elopement. Despite this, the resident managed to leave the facility on several occasions, including an incident where the resident was found at a convenience store parking lot, approximately ten minutes walking distance from the facility. The facility's records indicated that the resident had a history of wandering and had previously been found outside the facility on multiple occasions. Staff interviews revealed that the resident was known to be exit-seeking and had attempted to leave the facility using door codes. However, there was a lack of consistent communication among staff regarding the resident's elopement risk, and some staff members were unaware of the resident's tendencies. Additionally, the facility had issues with exit doors not locking properly, which contributed to the resident's ability to leave the premises. The facility did not conduct investigations into several of the resident's elopement incidents, and there was a lack of individualized care planning to address the resident's specific needs and risks. The failure to implement effective interventions and ensure secure exit doors led to the resident's repeated unsupervised departures, placing the resident at risk for serious injury or death.
Removal Plan
- The facility placed Resident 9, who was at the highest risk for elopement, on one-to-one supervision and was care planned accordingly to prevent any possibility of elopement.
- The facility would perform a full facility chart audit to identify any other residents at risk for elopement and their care plans would be updated.
- A facility wide inspection would be conducted by the environmental services team and nursing staff to identify any doorways that may not be properly secured. All doors would be inspected to ensure locking mechanisms are functional. Any issues identified would be resolved.
- A staff-wide education had begun and all staff would be in-serviced on the elopement policy, elopement binder, and all residents at risk for elopement and their care plans. Alerting administration of attempted or actual elopements, ensuring doors remain locked. All staff would sign off on this education prior to beginning their next shift. Any agency or outside staff would be alerted regarding the elopement procedures and policy and would be shown where the elopement binder was and associated policies were located.
- The administrator or designee would audit all doors to ensure locking mechanisms were functioning and doors were locked and results would be taken to QAPI to identify any further trends and concerns.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Molalla
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marquis Hope Village | 8.4 mi | ★★★★★ | 0 | 0 |
| Mt Angel Health And Rehabilitation | 11.8 mi | ★★★★★ | 9 | 0 |
| Marquis Oregon City Post Acute Rehab | 12.6 mi | ★★★★★ | 5 | 0 |
| Rivercrest Post Acute | 13 mi | ★★★★★ | 20 | 0 |
| Marquis Wilsonville Post Acute Rehab | 13.4 mi | ★★★★★ | 3 | 0 |
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