Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 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.
The facility did not conduct annual performance reviews for five CNAs, as required for competent staffing. Personnel records showed that CNAs hired between 2008 and 2017 had not received evaluations, a fact confirmed by HR/Payroll staff.
The facility did not ensure CNA staff received the required 12 hours of annual in-service training. Five CNAs were found to have incomplete training hours, with two having zero hours, two having 8 hours, and one having 11 hours. This was confirmed by HR and acknowledged by the Administrator.
The facility failed to provide a homelike dining environment by serving meals with plastic spoons, glasses, and Styrofoam cups. A resident expressed dissatisfaction with the plastic utensils, and staff confirmed the use of these items due to a shortage of regular cutlery. Multiple residents complained about the dining experience feeling like a fast food restaurant.
The facility failed to secure medication and treatment carts, leaving them unlocked and unattended on multiple occasions. This included carts containing prescription medications, inhalers, wound treatment supplies, and insulin. These lapses were confirmed by staff and reported to the Interim DNS.
The facility was found to have unsanitary conditions in the kitchen, with a pink/black substance on the ice machine and a black substance with clear slime in the ice scoop container. The Maintenance Director and Administrator acknowledged these issues, indicating a need for cleaning.
A resident reported being inappropriately touched by another resident, but the facility failed to report the allegation to the State Agency within the required two-hour timeframe. The delay was due to staff misunderstanding the reporting requirements and being unable to reach a nurse manager. The incident involved two residents with intact cognition, and the failure to report promptly placed residents at risk.
The facility failed to inform two residents and/or their representatives about the risks and benefits of psychotropic medications and did not obtain informed consent before administration. Despite the facility's policy requiring informed consent, Resident 34 received buspirone, sertraline, and clonidine, and Resident 66 received quetiapine without documented consent. The Interim DNS confirmed the expectation for nursing staff to review medication risks and benefits with residents prior to administration.
A resident with moderate cognitive impairment was verbally abused by another resident who was cognitively intact. The incident involved yelling and swearing, witnessed by staff and a family member. The affected resident felt scared and confused, while the aggressor admitted to losing control of emotions.
A facility failed to provide written transfer notices with appeal rights to a resident and their representative, and did not notify the State LTC Ombudsman of the resident's hospitalization. The resident, admitted with complications from a heart catheterization, was transferred to the hospital without the required notifications. Staff interviews revealed that the responsibilities for these notifications were not fulfilled, placing residents at risk of not being informed about their options and rights.
A facility failed to provide a resident with a written notice of its bed hold policy upon transfer to a hospital. The resident, admitted with complications from a heart catheterization, was transferred without receiving the required notice. The Interim DNS confirmed the oversight, noting the charge nurse was responsible for providing the policy.
The facility failed to follow physician orders for three residents, leading to potential adverse medication consequences. A resident with major depression and diabetes did not have their blood pressure and heart rate assessed before receiving clonidine and metoprolol, as required. Another resident with major depressive disorder missed applications of prescribed topical medications and doses of Protonix. A third resident with high blood pressure and sleep apnea received Prozasin despite having a systolic blood pressure below the prescribed threshold. Staff interviews confirmed these deficiencies.
A resident with major depression and diabetes consented to a vision examination, but the facility failed to schedule it, leaving the resident without glasses. Despite multiple requests from the resident, the examination was not completed, and staff confirmed the oversight.
A facility failed to provide trauma-informed care for a resident with PTSD and major depressive disorder. Despite being admitted in July 2022, the resident's PTSD was not assessed, and no care plan was developed to address potential trauma triggers. Staff interviews confirmed that trauma screenings should have been completed at admission, particularly for residents with PTSD, but this was not done.
A resident with moderate cognitive impairment was observed smoking unsupervised in the courtyard, contrary to the facility's Smoking Policy requiring supervision for residents who do not meet safety criteria. This lack of supervision posed a risk of injury from fire hazards.
A resident, who was cognitively intact and had chronic kidney disease and heart failure, reported loaning money to a former CNA, which was not repaid. The facility initiated an investigation and suspended the staff member, but the staff member was no longer employed and could not be interviewed. The administration was informed of the findings but provided no further information.
Failure to Conduct Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received their annual performance reviews, which is a requirement for maintaining sufficient and competent staffing. During a review of personnel records conducted on November 6, 2024, it was found that five randomly selected CNAs, identified as Staff 6, 7, 8, 9, and 10, had not received their annual performance evaluations. These CNAs had hire dates ranging from 2008 to 2017, yet none had completed performance reviews. This oversight was confirmed by Staff 23, who is responsible for Human Resources and Payroll, indicating a lapse in the facility's processes for evaluating staff performance.
Deficiency in CNA Annual Training Hours
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistant (CNA) staff received the required 12 hours of annual in-service training, as evidenced by a review of training records and interviews. Specifically, five randomly selected CNA staff members did not meet the training requirement. Staff 6 and Staff 9 had zero hours of annual training, while Staff 7 and Staff 10 each had only 8 hours, and Staff 8 had 11 hours. This deficiency was confirmed by Staff 23 from Human Resources/Payroll, who provided the list of training hours, and acknowledged by Staff 1, the Administrator, who confirmed the requirement for 12 hours of annual in-service training for CNA staff.
Failure to Provide Homelike Dining Environment
Penalty
Summary
The facility failed to ensure a homelike environment for residents during dining, as observed between 11/5/24 and 11/8/24. Meals were served using plastic spoons, plastic glasses, and Styrofoam cups, which residents and staff identified as not homelike. Resident 66 expressed dissatisfaction with the plastic utensils, describing them as inadequate. Staff 29, a CNA, confirmed that residents typically received regular cutlery but had been using plasticware for at least a month. Staff 30, the Dietary Manager, acknowledged the lack of sufficient glasses, cups, and silverware for meal service, leading to the use of plastic and Styrofoam items. Staff 13, the Activities Director, reported multiple resident complaints about the dining experience resembling a fast food restaurant rather than a homelike setting.
Medication and Biologicals Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications and biologicals were securely stored, as required by their policy. Observations revealed that medication and treatment carts were left unlocked and unattended on multiple occasions. On Hall 1, a treatment cart was found unlocked without the nurse in view, and this was confirmed by an LPN. Similarly, on Hall 3, a medication cart containing prescription medications and inhalers was left unlocked and unattended, which was also confirmed by another LPN. Additionally, a treatment cart on Hall 1 was observed to be unlocked and unattended, containing wound treatment supplies, equipment for checking blood sugar levels, and residents' insulin. An LPN confirmed this lapse. Furthermore, both a treatment cart and a medication cart were found near the south entrance, with the treatment cart unlocked and the computer on the medication cart open to a resident's medical record, both unattended. These findings were confirmed by an RN, and the Interim DNS was notified of these issues.
Unsanitary Conditions in Ice Machine and Scoop
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, specifically concerning the ice machine and ice scoop. During an observation, a pink/black substance was found on a plastic shield inside the ice machine, with condensation dripping over it onto the ice. The Maintenance Director confirmed that the ice machine was cleaned monthly but acknowledged the presence of the substance, indicating it should be free of debris or contaminants. Additionally, the ice scoop was stored in a container with a black substance and clear slime at the bottom. Both the Maintenance Director and the Administrator acknowledged the unsanitary conditions of the ice machine and scoop container, recognizing the need for cleaning.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to timely report an allegation of sexual abuse involving two residents to the State Agency (SA). Resident 60, who had intact cognition and was admitted with a C-difficile infection, reported that Resident 13, also with intact cognition and admitted with diabetes and alcohol-induced cirrhosis, touched her/his genital area while she/he was asleep. The incident was reported to the facility staff on the morning of 10/27/24, but the SA was not notified until 11:05 AM, which was beyond the required two-hour timeframe for reporting such allegations. The delay in reporting was due to a misunderstanding of the reporting requirements by the facility staff. Staff 1, the Administrator, believed there was a 24-hour window for reporting unless there was serious bodily injury, and Staff 24, an LPN, was not familiar with the two-hour reporting requirement. Additionally, Staff 24 attempted to contact a nurse manager but was unsuccessful, leading to further delays. The Interim DNS acknowledged the confusion regarding the reporting timeframe, which resulted in the failure to report the allegation within the mandated period.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform residents and/or their responsible parties about the risks and benefits of psychotropic medications and did not obtain informed consent before administering these medications. This deficiency was identified for two residents who were part of a sample reviewed for unnecessary medications. The facility's policy on psychoactive medications, dated 8/1/24, mandates that informed consent must be obtained from the resident or their representative prior to the administration of any psychoactive medication. Resident 34, admitted in March 2023 with a diagnosis of major depressive disorder, was administered buspirone, sertraline, and clonidine without documented evidence of informed consent. Similarly, Resident 66, admitted in October 2024 with major depressive disorder, received quetiapine without documented consent. The Interim Director of Nursing Services (DNS) confirmed that it was expected for nursing staff to review the risks and benefits of psychotropic medications with residents before administration, which did not occur in these cases.
Verbal Abuse Incident Between Residents
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse, as evidenced by an incident involving two residents. Resident 19, who was admitted with diagnoses including infection and anxiety disorder and had moderate cognitive impairment, was verbally abused by Resident 17. Resident 17, who was cognitively intact and admitted with diagnoses including amputation and obesity, entered Resident 19's room and yelled and swore at them, demanding that they stop yelling and turn down their TV. This interaction was witnessed by several staff members and a family member. Staff members, including a Physical Therapy Assistant and a CMA, observed the incident and confirmed that Resident 17 shouted and cursed at Resident 19. Resident 19 expressed feeling scared and confused about the situation. Resident 17 admitted to having a tendency to lose control of their emotions and acknowledged yelling at Resident 19. The incident was reported to the facility's Administrator and Interim DNS, who were informed of the findings of the investigation.
Failure to Provide Transfer Notices and Notify Ombudsman
Penalty
Summary
The facility failed to provide written transfer notices with appeal rights to residents and their representatives, and did not notify the Office of the State Long-Term Care Ombudsman of resident hospitalizations. This deficiency was identified during the review of a case involving a resident who was admitted to the facility with complications from a foreign body left in the body following a heart catheterization. The resident was transferred to the hospital, but there was no evidence in the health record that a transfer notice with appeal rights was provided to the resident or their representative, nor was the Ombudsman notified of the transfer. Interviews with facility staff revealed that the responsibility for notifying the Ombudsman and providing written transfer notices was not fulfilled. Staff 28, responsible for notifying the Ombudsman, admitted to not having done so since August 2024. Additionally, Staff 2, the Interim Director of Nursing Services, confirmed that the charge nurse was supposed to complete the written notification of transfer, but this was not done for the resident in question. This lack of action placed residents at risk of not being informed about their options and rights during transfers.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide a written notice of its bed hold policy to a resident or their representative at the time of transfer to a hospital. This deficiency was identified during a review of the health record of a resident who was admitted to the facility in September 2024 with complications from a foreign body left in the body following a heart catheterization. The resident was transferred to the hospital on October 8, 2024, but there was no evidence in the health record that a written bed hold policy was provided at the time of transfer. Staff 2, the Interim Director of Nursing Services, confirmed that the charge nurse was responsible for providing this notice and acknowledged that it was not given to the resident upon transfer.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to ensure physician orders were followed for three residents, leading to potential adverse medication consequences. Resident 34, diagnosed with major depression and diabetes, was prescribed clonidine and metoprolol succinate ER with specific instructions to hold the medication if the systolic blood pressure (SBP) was less than 110 and/or heart rate (HR) was less than 55. However, the medication administration record (MAR) did not indicate that the resident's SBP and HR were assessed before administering these medications, as confirmed by staff interviews. This oversight was attributed to the MAR not being set up to alert staff to check these vital signs before medication administration. Resident 66, with a diagnosis of major depressive disorder, was prescribed Clindamycin Phosphate External and Diprolene External Ointment, both of which were not applied according to physician orders on multiple occasions. Additionally, Protonix, prescribed for gastric reflux, was not administered on several days despite being available in the facility's automated medication dispensing system. Staff interviews confirmed the missed applications and administrations, with no documentation explaining the omissions in the resident's health record. Resident 8, diagnosed with high blood pressure and sleep apnea, was prescribed Prozasin with instructions to hold the medication if the SBP was less than 110. The MAR revealed that Prozasin was administered on days when the resident's SBP was below the specified threshold, as confirmed by staff. This indicates a failure to adhere to physician orders, potentially placing the resident at risk for adverse effects. Staff interviews corroborated the findings, and no additional information was provided to explain the discrepancies.
Failure to Schedule Vision Examination for Resident
Penalty
Summary
The facility failed to assist a resident in obtaining necessary vision care, which placed the resident at risk for impaired vision. The resident, admitted in March 2023 with diagnoses including major depression and diabetes, consented to a vision examination in December 2023. However, a review of the resident's health record showed no evidence that the examination was scheduled or completed. Observations over several days in November 2024 revealed the resident was not wearing glasses. The resident reported that they were supposed to receive glasses the previous year but had not been scheduled for an examination despite multiple requests. Staff confirmed that the examination was authorized but never scheduled, indicating a lapse in the facility's process for managing the resident's vision care needs.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with Post-traumatic stress disorder (PTSD) and major depressive disorder. The resident was admitted in July 2022, but the Social Services Assessment conducted shortly after admission did not assess the resident's PTSD diagnosis. Furthermore, the resident's clinical record lacked evidence of a trauma assessment or a care plan addressing potential trauma triggers. Interviews with facility staff revealed that trauma screenings were supposed to be completed at admission, especially for residents with PTSD, but this was not done for the resident in question.
Failure to Supervise Resident During Smoking Activities
Penalty
Summary
The facility failed to ensure appropriate supervision for a resident with moderate cognitive impairment while smoking, which posed a risk of injury from fire hazards. The facility's Smoking Policy required residents who did not meet safety criteria to be supervised during smoking activities. Resident 106, who had diagnoses including diabetes mellitus and stroke, was identified as having moderate cognitive impairment with a BIMS score of 11. A Smoking Safety Evaluation indicated that the resident lacked adequate cognitive skills, did not recognize designated smoking areas, and could not identify proper smoking receptacles. Consequently, the resident was reassessed and designated as a supervised smoker. Despite this designation, on one occasion, Resident 106 was observed smoking a lit cigarette in the courtyard smoking area without any staff supervision. Staff 4, an LPN, confirmed the resident's presence in the smoking area without supervision. The facility's failure to provide the necessary supervision as per their policy placed the resident at risk for injury from fire hazards. The facility's administration was informed of these findings, but no additional information was provided.
Misappropriation of Resident's Property by Staff
Penalty
Summary
The facility failed to protect a resident from the misappropriation of property, specifically involving a financial transaction with a staff member. Resident 106, who was cognitively intact with a BIMS score of 15, had been admitted to the facility with chronic kidney disease and heart failure. The resident reported loaning money to a former CNA, identified as Staff 4, on several occasions. While previous loans were repaid, a loan of $700 made in May 2023 for new tires was not returned. The facility was aware of the situation and had initiated an investigation, which included suspending Staff 4. However, Staff 4 was no longer employed at the facility and could not be interviewed. The facility's administration and DNS were informed of the misappropriation findings but did not provide additional information.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Portland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| 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 August 2026) and official state health department websites.