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.
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A resident with mild cognitive impairment, poor safety awareness, and diabetic neuropathy, which reduced sensation in the feet, was known to slide out of bed at night. The bed was positioned too close to a baseboard heater, and the resident rolled out of bed and placed a foot directly on the heater. A CNA later found the resident on the floor with the foot on the heater, and assessment documented multiple small second-degree burns with blisters on the left foot and toes caused by direct contact with the heater.
The facility failed to maintain an effective pest control program, resulting in an ongoing roach infestation documented over several months. The contracted pest control provider serviced the building only once per month and reported continued evidence of roaches, while indicating that more frequent applications were needed. The Administrator acknowledged persistent roach problems throughout the facility, and several CNAs reported seeing roaches, with some noting that sightings were not consistently documented and one CNA unaware of the pest control log. This lack of consistent reporting and insufficient pest control measures placed residents at risk for exposure to household pests and increased health risks.
The facility failed to maintain a clean and homelike environment when a cognitively intact resident with anxiety reported that their room had not been cleaned for several days, and surveyors observed dirty floors, debris, dark stains in the toilet bowl, and a urine odor in the bathroom. The shared bathroom and multiple shower rooms were also found with dark substances on toilet surfaces, unclean baseboards, and unkept conditions. Only one housekeeping staff member, the Director of Housekeeping, was working at the time of the survey, and leadership acknowledged an expectation that resident areas be clean.
A resident with diabetes and a history of lower extremity wounds had orders and care plans for weekly diabetic foot checks, weekly head‑to‑toe skin inspections, and daily foot monitoring, yet staff documented completed assessments with no issues while the resident’s legs and feet were not actually visualized, refusals were not consistently documented, and the provider was not notified despite the resident later being observed with dirty, adherent socks, a malodorous, raw‑appearing ankle area, and a blood‑tinged bandage stuck to the skin. Another resident with diabetes on hemodialysis had multiple scheduled and sliding‑scale insulin aspart doses administered significantly later than ordered, with no progress notes explaining the delays, while the resident and an RN reported that nighttime insulin was often late. A third resident admitted with anxiety and panic disorder had ordered lorazepam not available on the night of admission due to the prescription not being sent to the pharmacy, was unable to receive a dose from the backup supply because of a dose mismatch, and did not receive scheduled doses the following day, with no documented follow‑up by nursing on the cause or status of the delayed medication.
The facility failed to provide ordered PT, OT, and SLP services and to complete timely therapy evaluations for several residents. One resident with a stroke and fall history was ordered PT, OT, and SLP; PT was delivered less frequently than prescribed, SLP treatments were not documented after being ordered, and OT evaluation occurred weeks late with only limited OT sessions provided. Another resident with diabetes and protein-calorie malnutrition was discharged from the hospital with a mechanical soft diet and SLP orders but did not receive an SLP assessment for over two weeks and remained on modified textures until then. A third resident with muscle weakness had an OT order but did not receive an OT evaluation for more than two months and reported never receiving OT, which was corroborated by multiple CNAs and an RN. A fourth resident with an anoxic brain injury and femur fracture had an orthopedic PT order that was never acknowledged or communicated to therapy, and no PT was provided. Staff, including the Administrator and rehab leadership, confirmed these lapses and delays in therapy services and evaluations.
A resident admitted with spinal stenosis, chronic back pain, anxiety, panic disorder, and opioid dependence had a PRN hydrocodone-acetaminophen order entered on admission, but the medication was not available for use until the early morning of the next day. The admitting LPN reportedly told the resident and a complainant that the pain medication would arrive within a few hours, yet the prescription was not sent to the pharmacy, and there was no documentation of follow-up or explanation for the delay. During the night, the resident repeatedly requested pain medication, reported significant pain to a CNA and to a complainant by phone, and an RN later confirmed the drug was unavailable until a new prescription and access to backup stock were obtained.
A significant med error occurred when an LPN gave a resident 12 meds intended for another resident instead of the resident’s scheduled morning meds. The resident, who was cognitively intact and had HTN, reported feeling weak after taking the pills, and staff later found very low BP. The resident was sent to the hospital and diagnosed with bradycardia, hypotension, and transient circulatory shock secondary to an unintentional medication overdose, requiring ICU care and vasopressor support.
Unsecured Medication and Treatment Carts: Medication and treatment carts on the 200 Hall were observed unlocked on multiple occasions while staff were away from them or out of sight. An RN, an LPN, and another RN each confirmed the carts were unlocked, and residents’ prescribed medications and a treatment cart containing insulin and needles were inside. Staff stated carts were expected to be locked whenever unattended.
Failure to perform hand hygiene during wound care was observed for a resident with diabetes and a pressure ulcer. An LPN removed the old dressing and adjusted the resident’s incontinent brief, then acknowledged gloves should have been changed when moving from a dirty task to a clean task and that hand hygiene should have been performed before putting on clean gloves. The DNS stated staff were expected to follow infection control standards, including changing gloves as needed and performing hand hygiene when gloves were removed.
Incomplete Care Plans for Wound VAC and Behavioral Needs: Two residents had care plans that did not include needed interventions tied to wound VAC care, and one resident’s plan also lacked target behaviors and interventions related to anxiety and depression meds. Staff acknowledged the missing care plan information for the wound and psychotropic-related needs.
Resident Burn from Contact with Baseboard Heater Due to Inadequate Hazard Prevention
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was protected from accident hazards related to a baseboard heater, resulting in second-degree burns. The resident had diagnoses including stroke and diabetic neuropathy, a condition causing numbness in the hands and feet, and was care planned for impaired cognition and poor safety awareness, including sliding out of bed at night and fidgeting with items on the walls. The resident’s MDS showed mild cognitive impairment with a BIMS score of 13/15. Despite these known risks, the resident’s bed was positioned too close to a baseboard heater in the room. On the night of the incident, the resident rolled out of bed and placed their left foot on the baseboard heater. A CNA found the resident lying on the floor, whimpering, with the left foot resting on the heater. Due to the resident’s diabetic neuropathy, staff reported the resident would not have been aware of the injury as it was occurring. The CNA removed the resident’s foot from the heater and notified the charge nurse. Subsequent assessment and a Skin and Wound Assessment documented second-degree burns with multiple small blisters on the left foot and toes, each approximately 0.2 cm in length and width. The administrator and RN case manager acknowledged that the burns were caused by direct contact with the baseboard heater after the resident rolled out of bed.
Failure to Maintain Effective Pest Control for Ongoing Roach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by ongoing roach activity documented over several months and corroborated by staff and the contracted pest control provider. On 4/22/26, the contracted pest control technician (Witness 9) was observed placing roach traps and reported that, per contract, he only serviced the facility once per month. He stated he had seen evidence of roaches for months, though not rodents, and indicated that the facility really needed pest control services twice per month to eradicate the roaches. Review of the Pest Control Log on 4/22/26 showed roach sightings reported from 10/2025 through 4/2026. The Administrator (Staff 1) acknowledged ongoing roach concerns throughout the facility and stated he had asked the pest control provider during past and recent monthly visits for more frequent service to control pests, especially roaches. Multiple CNAs (Staff 43, Staff 44, and Staff 27) reported seeing roaches in the facility, with Staff 43 and Staff 44 stating that sightings were not always written or reported in the Pest Control Log, and Staff 27 stating she was unaware of the Pest Control Log for reporting pest sightings. On 4/27/26, the Administrator confirmed the ongoing roach issue and stated he expected the facility to be pest free. This deficiency placed residents at risk for exposure to household pests and increased health risks, as the facility did not ensure that pest sightings were consistently documented or that pest control services were provided at a frequency sufficient to address the persistent roach problem.
Failure to Maintain Clean and Homelike Resident Rooms and Bathrooms
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment when resident rooms, shared bathrooms, and shower rooms were observed to be unclean and poorly maintained. Resident 41, admitted in 2025 with diagnoses including anxiety and assessed as cognitively intact on a 1/28/26 Quarterly MDS, reported that the room was not cleaned regularly and had not been cleaned since 4/17/26, attributing this to the facility often being short staffed. On 4/19/26, surveyors observed that the floor in the resident’s room appeared unwashed with dark spots around the toilet and throughout the bathroom, and later that day the room had a dirty floor with debris, dark stains in the toilet bowl, and a bathroom that smelled of urine. The shared bathroom for the room was also observed with dark stains in the toilet bowl. On 4/19/26, Staff 19, the Director of Housekeeping, was observed to be the only housekeeping staff working in the facility and confirmed he was the only person working in housekeeping when the survey team entered. During a subsequent facility walkthrough on 4/24/26 with Staff 19 and Staff 20, the Regional Director of Housekeeping, they confirmed the presence of a dark substance on the toilet seat, handle, and tank in the shared bathroom, as well as unclean floor baseboards in the room. They also confirmed that resident shower rooms on all three halls appeared unclean and unkept, with items left in the rooms. The Administrator later acknowledged during a walkthrough that he expected residents’ rooms and areas to be clean.
Failure to Monitor Skin, Administer Insulin Timely, and Provide Ordered Anxiolytic Medication
Penalty
Summary
The deficiency involves failures to provide treatment and care according to physician orders and residents’ needs in the areas of skin monitoring, insulin administration, and psychotropic medication management for three residents. For one resident with diabetes and a history of bilateral lower extremity and right foot wounds, the wound care provider documented that all wounds had healed and recommended ongoing monitoring for reopening or new wounds. The resident’s care plans and physician orders required weekly diabetic foot checks, weekly head‑to‑toe skin inspections, daily inspection of the feet during ADLs, and notification of the provider and resident care manager of any new skin issues or refusals. Documentation on the TAR showed that weekly diabetic foot checks and skin inspections were marked as completed with no issues, and a quarterly nursing evaluation indicated no skin integrity concerns, despite the resident’s documented routine refusals of care. During observation, the resident was found wearing pants, thick socks, and heavy boots, and reported having trouble with socks and leg pain for a couple of months. When the resident pulled up a pant leg, the surveyor observed a dark red sock covered in flaked skin, bright red and raw‑appearing skin with a large indent at the ankle, a malodorous odor, and a dirty, blood‑tinged bandage stuck to the skin under the sock. The resident’s socks appeared dirty and covered in flaked skin, and the resident’s speech was disorganized. Staff interviews revealed that some nurses did not complete skin checks, a CNA had never visualized this resident’s legs or feet due to refusals to shower or remove shoes, and the LPN who documented a head‑to‑toe skin inspection stated she had never actually completed one for this resident and did not recall the documented assessment. Another LPN stated she had never assessed the resident’s feet and that her TAR entries reflected refusals, but she had not notified the provider. The resident care manager and DNS acknowledged uncertainty about when to notify the provider and confirmed the provider had not been notified of repeated refusals of skin inspections or diabetic foot checks. For a second resident with diabetes requiring hemodialysis, physician orders required scheduled insulin aspart doses with meals and additional sliding‑scale insulin before meals and at bedtime at specific times. Review of the diabetic administration record showed multiple instances where both scheduled and sliding‑scale insulin doses were administered significantly later than the ordered times, with no documentation in the clinical record explaining the delays. The resident reported that insulin was often not administered timely, especially at bedtime, and described being a brittle diabetic for whom timely insulin was very important. An RN confirmed that the resident’s blood sugars dropped quickly and that the resident had reported late nighttime insulin administration, and stated that night shift nurses could become busy and unable to give insulin on time. The resident care manager confirmed the late administrations, stated that nurses were required to write progress notes when insulin was given late, and acknowledged that no such notes were present for the identified dates. For a third resident admitted with spinal stenosis, anxiety disorder, panic disorder, and opioid dependence, admission orders included lorazepam 1 mg tablets scheduled twice daily and an additional PRN evening dose for generalized anxiety disorder. The MAR showed that the scheduled lorazepam doses were not administered at the ordered morning and midday times on the day after admission, and that the PRN evening dose was instead administered in the morning, contrary to the order. The admitting LPN did not recall the resident or any issues with lorazepam delivery and had no documentation clarifying whether or when the prescription was sent to the pharmacy. The complainant reported that the admitting nurse had told the resident the lorazepam would arrive within a few hours, but the resident later called in distress stating the medication was not available; when the complainant contacted the facility, they were told the prescription had not been sent to the pharmacy. A CNA stated the resident was agitated the night of admission, requested anti‑anxiety medication several times, and called the complainant twice about not receiving medication. The night RN confirmed the resident appeared agitated, that the lorazepam order had not been sent to the pharmacy, that the medication was not available, and that a pull from the backup supply was denied due to a dose mismatch, resulting in the resident not receiving lorazepam the night of admission or the scheduled doses the following day, with no documented follow‑up on the delay in the medical record.
Failure to Provide Ordered PT, OT, and SLP Services and Timely Evaluations
Penalty
Summary
The deficiency involves the facility’s failure to provide specialized rehabilitative services as ordered for multiple residents. One resident admitted with a stroke and history of falls had physician orders for PT, OT, and SLP evaluations and treatments as indicated. PT assessed this resident for therapy five times per week for a defined certification period, but documentation showed PT was only provided four times per week during several weeks. SLP initially did not recommend services, but after a subsequent assessment on 1/19/26, the resident was ordered SLP twice weekly for 60 days, with no documentation of any SLP treatments after that date. OT did not evaluate this resident until 42 days after admission, and although OT determined a need for services five days per week for 60 days, the resident received OT on only a limited number of dates before discharge. The Administrator confirmed that therapy services were not provided as prescribed and that evaluations were not completed within the expected timeframe. Another resident, with diagnoses including diabetes and mild protein-calorie malnutrition, was transferred from the hospital with orders for a mechanical soft diet and SLP evaluation and treatment. The SLP assessment did not occur until 17 days after readmission, during which time the resident continued on mechanical soft diet textures. The resident reported it took about a month to get off puree foods and stated they were told the facility needed to hire more SLP staff before an assessment could be completed. The Regional Director of Rehabilitation and the Administrator both confirmed the delay in SLP assessment and were unable to explain why the evaluation was not completed sooner, despite existing orders for SLP evaluation and treatment. A third resident admitted with muscle weakness had physician orders dated 2/12/26 for OT evaluation and treatment, but the OT evaluation was not completed until 4/20/26. The admission MDS indicated the resident had not received any therapy services in the seven days prior to that assessment. The resident stated they had not received OT and were interested in therapy to help them leave the facility. Multiple CNAs and an RN reported they had never observed this resident working with therapy since admission. The Rehabilitation Director acknowledged the OT evaluation was not timely and cited difficulty maintaining Certified Occupational Therapy Assistants. In a fourth case, another resident with anoxic brain injury and a right femur fracture had an orthopedic order for PT, but the clinical record contained no evidence that the PT order was acknowledged, clarified, or communicated to the therapy department, and the resident did not receive PT. An RN case manager stated the order must have been missed and confirmed that therapy was not provided.
Failure to Ensure Timely Availability of Ordered PRN Opioid for New Admission
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a cognitively intact resident admitted with spinal stenosis, dorsalgia, anxiety disorder, panic disorder, and opioid dependence. On admission, the resident had an order for hydrocodone-acetaminophen 10 mg-325 mg every four hours as needed for pain, entered on the Medication Administration Record on the day of admission. However, the first documented administration of this medication did not occur until the early morning of the following day. During this period, the ordered hydrocodone-acetaminophen was not available in the facility because the prescription had not been sent to the pharmacy, and there was no documentation by the admitting nurse explaining the delay or any follow-up on obtaining the medication. According to interviews, the admitting nurse reportedly told the resident and a complainant that the hydrocodone-acetaminophen would arrive within a few hours of admission, but by late that night the resident was calling the complainant in distress, reporting pain and lack of access to the medication. A CNA stated the resident was in pain, agitated, and repeatedly requested pain medication, and that these requests were reported to the nurse. An RN on the night shift confirmed receiving a call from the complainant about the resident’s pain and discovered that the prescription had not been sent to the pharmacy, prompting a request to the on-call provider and use of the backup supply before the first dose was finally administered. Resident care managers later stated that, given the resident’s condition and admission from home without a hard copy prescription, the admitting nurse should have obtained a STAT prescription and documented diligent follow-up, but the record contained no such documentation and the medication was not readily available when requested.
Medication Error Resulted in Hospitalization for Hypotension and Shock
Penalty
Summary
A significant medication error occurred when a licensed nurse administered another resident’s medications to a cognitively intact resident with diagnoses including post-surgical digestive system aftercare and essential hypertension. The resident’s medication administration record showed scheduled morning medications including amiodarone, losartan, and metoprolol, and the resident stated that on the morning of the error the nurse gave more pills than usual and told the resident this was the correct amount. The resident reported feeling very weak after taking the medications. The nurse later stated he accidentally gave the resident 12 medications intended for another resident and did not follow the five rights of medication administration, explaining that he was distracted and unfamiliar with the area. Staff observed the resident to be unusually confused that morning, and the resident’s blood pressure was found to be very low after the error was recognized. The resident was sent to the hospital, where records showed bradycardia, hypotension, and transient circulatory shock secondary to unintentional medication overdose, requiring ICU admission and vasopressor support.
Unsecured Medication and Treatment Carts
Penalty
Summary
Medication and treatment carts on the 200 Hall were observed unsecured during multiple survey observations, contrary to the facility’s Security of Medication Cart policy, which required carts to be locked during medication pass, before a nurse entered a resident’s room, and whenever the cart was out of the nurse’s view. On 4/20/26, an RN was observed standing next to an unlocked medication cart and then walking away from it before locking it; she stated she did not have the key because she was not in charge of the cart and could not find the person responsible for it, while confirming residents’ prescribed medications were in the cart. On 4/21/26, an unlocked treatment cart was observed in the 200 Hall while an LPN and another staff member were in the bistro area and not within sight of the cart; the LPN confirmed the cart was unlocked and stated the expectation was to lock medication and treatment carts whenever walking away from them. On 4/23/26, another unlocked medication cart was observed in the 200 Hall, and an RN confirmed it was unlocked and that residents’ prescribed medications were inside; she stated she was distracted and more accustomed to working night shift. Later that day, the DNS stated staff were expected to lock medication and treatment carts whenever away from them for safety purposes.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure hand hygiene was performed during wound care for Resident 7, who was admitted in 3/2026 with a diagnosis of diabetes and was being treated for a pressure ulcer. During observation on 4/21/26 at 11:14 AM, an LPN removed the resident’s old pressure ulcer dressing and adjusted the resident’s incontinent brief, then was stopped by the surveyor before cleaning the pressure ulcer. The LPN stated he should have changed gloves when moving from a dirty task to a clean task, then removed the gloves and was stopped again before putting on clean gloves to ensure hand hygiene was performed. The facility’s Standard Precautions policy stated hand hygiene was to be performed when hands were not visibly soiled and gloves were to be changed as necessary during care to prevent cross-contamination when moving from a dirty site to a clean site. On 4/24/26, the DNS stated staff were to follow infection control standards including changing gloves as needed and performing hand hygiene when gloves were removed.
Incomplete Care Plans for Wound VAC and Behavioral Needs
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for 2 of 7 sampled residents reviewed for unnecessary medications and skin conditions. Resident 6 was admitted with diagnoses including surgical wound infection and adjustment disorder with depressed mood. The admission MDS showed a history of depression, use of medication for anxiety, and a wound VAC. Physician orders included care for the wound VAC, hydroxyzine for anxiety, and duloxetine for depression, but the comprehensive care plan did not include interventions related to the wound VAC, target behaviors, or interventions related to mood or anxiety associated with hydroxyzine and duloxetine. Resident 7 was admitted with diagnoses including a pressure wound and malnutrition. The admission MDS identified a wound VAC, and physician orders included care for the wound VAC. However, the revised comprehensive care plan did not include any interventions related to the wound VAC. During interviews, staff acknowledged that Resident 6’s care plan lacked wound VAC information and target behaviors or interventions for hydroxyzine and duloxetine, and that Resident 7’s care plan contained no information related to the wound VAC.
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