How many inspection deficiencies does STANLEY POST ACUTE have?

STANLEY POST ACUTE has 37 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at STANLEY POST ACUTE?

STANLEY POST ACUTE has a three-star staffing rating from CMS with 0.20 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is STANLEY POST ACUTE located?

STANLEY POST ACUTE is located in MILWAUKIE, OR. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does STANLEY POST ACUTE have?

STANLEY POST ACUTE has 96 certified beds.

Who owns STANLEY POST ACUTE?

STANLEY POST ACUTE is a for profit - limited liability company facility and is part of the PACS GROUP chain.

What questions should families ask when visiting STANLEY POST ACUTE?

Families visiting STANLEY POST ACUTE should ask about staff retention and training programs. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does STANLEY POST ACUTE compare to other nursing homes?

STANLEY POST ACUTE has a 4-star overall rating, placing it above average compared to other nursing homes in OR. Higher-rated facilities typically have better inspection results and staffing levels.

STANLEY POST ACUTE

Q: What is STANLEY POST ACUTE's CMS rating?

STANLEY POST ACUTE has a four-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

Q: Is STANLEY POST ACUTE safe?

STANLEY POST ACUTE has a clean safety record with no substantiated abuse findings, no immediate jeopardy citations, and is not on any federal watch list.

Q: Do nurses at STANLEY POST ACUTE stick around?

STANLEY POST ACUTE has high staff turnover at 62%. High turnover can mean less continuity of care as staff change frequently.

Q: Was STANLEY POST ACUTE ever fined?

No, STANLEY POST ACUTE has no federal fines on record, indicating a clean compliance history with Medicare and Medicaid requirements.

Q: Is STANLEY POST ACUTE on any federal watch list?

No, STANLEY POST ACUTE is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

12045 SE STANLEY AVENUE, MILWAUKIE, OR 97222 · (503) 659-2323

For profit - Limited Liability company 96 Beds PACS GROUP Data: November 2025

Trust Grade

65/100

#46 of 127 in OR

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Last Inspection: September 2025

Inspected within the last 6 months. Data reflects current conditions.

Overview

Stanley Post Acute in Milwaukie, Oregon, has a Trust Grade of C+, indicating it is slightly above average but not exceptional. It ranks #46 out of 127 nursing homes in Oregon, placing it in the top half of facilities statewide, and #7 out of 13 in Clackamas County, meaning there are only six local options considered better. The facility is improving, with issues decreasing from 14 in 2024 to 9 in 2025. Staffing is a concern, rated 3 out of 5 stars, with a high turnover rate of 62%, significantly above the state average. While there have been no fines, which is positive, the facility has less RN coverage than 99% of Oregon facilities, which could impact resident care. Specific incidents of concern include the failure to properly clean reusable medical equipment and a lack of hand hygiene during medication passes, which could expose residents to infections. Additionally, there were issues with incomplete assessments for residents with specific needs, potentially affecting their treatment. Overall, while there are some strengths, including a good overall rating and no fines, the facility has significant areas needing improvement, particularly in infection control and staffing practices.

Trust Score: C+
In Oregon: #46/127
Safety Record: Low Risk
Inspections: Getting Better
Staff Stability: 62% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: No fines on record. Clean compliance history, better than most Oregon facilities.
Skilled Nurses: Each resident gets only 12 minutes of Registered Nurse (RN) attention daily — below average for Oregon. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 37 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★★★☆

4.0

Overall Rating

★★★☆☆

3.0

Staff Levels

★★★☆☆

3.0

Care Quality

★★★★☆

4.0

Inspection Score

↔

Stable

2024: 14 issues

2025: 9 issues

The Good

Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in fire safety.

The Bad

Staff Turnover: 62%

16pts above Oregon avg (46%)

Frequent staff changes - ask about care continuity

Chain: PACS GROUP

Part of a multi-facility chain

Ask about local staffing decisions and management

Staff turnover is elevated (62%)

14 points above Oregon average of 48%

The Ugly 37 deficiencies on record

Sept 2025 6 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

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Based on interview and record review it was determined the facility failed to inform the resident of the risks and benefits of a psychotropic medication for 1 of 5 sampled residents (#37) reviewed for unnecessary medications. This placed residents of risk of being uninformed. Findings included: Resident 37 admitted to the facility in 2025 with diagnoses including insomnia and depression. A 6/11/25 physician order indicated 25mg quetiapine fumarate (antipsychotic) related to insomnia for Resident 37. An updated 7/10/25 physician order indicated an increase of the quetiapine fumarate to 50mg related to depression. Review of Resident 37's medical record revealed no indication the resident was informed of the risks and benefits of the use of quetiapine fumarate.On 9/4/25 at 2:00 PM Staff 2 (DNS) acknowledged there was no evidence in Resident 37's medical record a risk and benefits of the quetiapine fumarate was completed.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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Based on interview and record review it was determined the facility failed to ensure resident advance directives were available for 2 of 4 sampled residents #s 46 and 96) reviewed for advance directives. This placed residents at risk for not having their end of life preferences honored. Findings include:The facility's 9/2024 Advance Directive policy indicated residents were to be asked about, and provided with information about, advance directives upon admission and quarterly thereafter.1.Resident 46 admitted to the facility in 2021 with diagnoses including diabetes.A 12/2023 POLST (Physician Order for Life Sustaining Treatment) indicated Resident 46's family member was the medical power of attorney.Resident 46's care plan, revised on 8/14/25, indicated the resident had an advance directive. The resident's advance directive was to be honored and kept in the medical record at all times.A review of Resident 46's medical record revealed neither the medical power of attorney form nor the advance directive were on file.On 9/3/25 at 12:36 PM Resident 46 stated she/he completed an advance directive with her/his family.On 9/3/25 at 1:42 PM Staff 12 (Social Services) was asked about Resident 46's advance directive and indicated a POLST (Physician Orders for Life Sustaining Treatment) was on file. Staff 12 indicated she was not familiar with the difference between a POLST and an advance directive and used the terms interchangeably. Staff 12 acknowledged Resident 46's advance directive was not in the resident's clinical record.2. Resident 96 readmitted to the facility in 4/2025 with diagnoses including multiple sclerosis. The resident's care plan, updated 6/3/25, indicated Resident 96 had an advance directive. The advance directive was to be honored.A review of the resident's clinical record revealed the advance directive was not on file. On 9/3/25 at 12:31 PM Resident 96 indicated she/he completed an advance directive while residing in the facility. On 9/3/25 at 1:42 PM Staff 12 (Social Services) was asked about Resident 96's advance directive and indicated a POLST (Physician Orders for Life Sustaining Treatment) was on file. Staff 12 indicated she was not familiar with the difference between a POLST and an advance directive and used the terms interchangeably. Staff 12 acknowledged Resident 96's advance directive was not in the resident's clinical record.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

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Based on interview and record review it was determined the facility failed to consistently provide restorative services to maintain range of motion for 1 of 1 sampled resident (#96) reviewed for mobility. This placed resident at risk for decreased range of motion. Findings include:Resident 96 was admitted to the facility in 8/2022 with a diagnosis of multiple sclerosis. A 3/18/2025 Restorative Nursing Referral revealed Resident 96 was to receive passive ROM exercises for her/his right and left lower extremities. Resident 96's 7/31/25 Annual MDS revealed she/he was cognitively intact, had ROM impairment on both sides of her/his lower extremities and received no passive ROM during the seven-day look back period. Resident 96's Comprehensive Care Plan last revised on 8/18/25 included a restorative nursing program to address her/his risk for decreased range of motion which included bilateral knee and right hip passive ROM exercises. A review of Resident 96's ROM Program Task tracking form from 8/5/25 through 9/3/25 and a restorative nursing services binder revealed no documentation of restorative services were provided for Resident 96. The restorative nursing binder indicated Resident 96 was to receive ROM to her/his lower extremities. On 9/3/25 at 2:35 PM Resident 96 stated staff no longer provided ROM exercises for her/his legs. On 9/4/25 at 11:47 AM Staff 6 (CNA) stated the restorative nursing services binder indicated to staff which residents were supposed to be offered exercises but was unaware if Resident 96 received restorative services. On 9/4/25 at 1:30 PM Staff 7 (CNA) stated she did not provide passive ROM exercises to Resident 96's lower extremities when she worked with her/him. On 9/5/25 at 11:43 AM and 11:46 AM Staff 5 (LPN Resident Care Manager) stated Resident 96 had a restorative program to address her/his risk for contractures. Staff 5 stated the facility previously had a designated restorative aide, but CNAs were currently responsible to provide restorative services to residents. Staff 5 stated she expected staff to provide Resident 96 passive ROM exercises for her/his lower extremities as indicated in her/his care plan.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review it was determined the facility failed to ensure proper labeling of biologicals for 1 of 2 treatment carts reviewed for medication storage. This placed residents at risk for reduced efficacy of medication. Findings include:On 9/4/25 at 7:00 PM Staff 3 (LPN) was observed to prepare insulin glargine for Resident 44, there was no open date on the insulin vial. The manufacturer's instructions indicated the medication was to be discarded 28 days after opening.On 9/4/25 at 7:00 PM Staff 3 acknowledged the insulin glargine vial was open with no open date.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Dental Services (Tag F0791)

Could have caused harm · This affected 1 resident

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Based on interview and record review it was determined the facility failed to assist a resident with obtaining dentures for 1 of 2 sampled residents (#3) reviewed for dental care. This placed residents at risk for decreased quality of life. Findings include:Resident 3 admitted to the facility in 1/2025 with diagnoses including blindness. A 2/1/25 admission MDS indicated Resident 3 had no dental concerns. A 7/8/25 progress note indicated a physician ordered new bottom dentures for Resident 3. A 7/8/25 physician order indicated a new bottom denture was to be fabricated. No further information related to the new lower denture was found in the resident's clinical record. On 9/2/25 Resident 3 stated she/he had a dental appointment two months ago and was supposed to receive a new lower denture, but she/he did not receive anything and was unsure why. On 9/3/25 at 1:42 PM Staff 12 (Social Services) stated she was typically involved with assisting residents acquiring dentures but she was unaware of Resident 3's new order for a new lower denture. On 9/3/25 at 3:16 PM Staff 5 (LPN Resident Care Manager) indicated she was unaware of the resident's order for a new lower denture. Staff 5 acknowledged no follow-up was completed regarding the order since the appointment two months ago.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to use appropriate disinfection practices for reusable medical equipment, failed to ensure the community use CBG glucometer was properly cleaned and sanitized between resident use, and failed to ensure hand hygiene was completed for 1 of 4 halls reviewed for infection control and meal service, and 1 of 1 sampled resident (#44) reviewed during medication pass. This placed all residents who required CBG checks at risk for exposure to infections including bloodborne illness and placed residents at risk for cross contamination. Findings include:The facility policy Guidelines for Cleaning and Disinfection of Non-Critical Resident Care Items dated 9/1/24 indicated: Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). 1.On 9/4/25 at 6:59 AM, Staff 4 (CNA) was observed exiting room [ROOM NUMBER] with a rolling vitals cart which contained reusable vitals equipment without cleaning the reusable vitals equipment. Staff 4 walked across the hall to room [ROOM NUMBER] and began to enter the room with the vitals cart without cleaning the vital equipment. Staff 4 stated she did not clean the vitals equipment because room [ROOM NUMBER] did not have wipes, so she was going to clean the vitals equipment at the next resident's bedside with their wipes. Staff 4 walked across the hall to a precautions cart which had a package of FitRight Wet Wipes (personal care wipes) and used the personal care wipes to clean the vitals equipment. Staff 4 stated she was to use the purple alcohol wipes (Super Sani-Cloth wipes), but CNAs no longer had access to them, so she used the resident personal care wipes to clean the reusable vitals equipment. Staff 4 stated the personal care wipes were used to clean the residents, so it was okay to clean the vitals equipment. On 9/4/25 at 8:19 AM, Staff 2 (DNS) stated the facility staff were to clean the reusable vitals equipment between each resident with the Super Sani-Cloth wipes and stated the personal care wet wipes were not acceptable because it did not have the appropriate germicide. 2. The blood glucose monitoring system manufacturer instructions indicated to disinfect the meter with EPA-registered wipes. The 8/1/24 facility policy and procedure indicated to clean glucometers according to manufacturer’s recommendation using EPA approved disinfectants to protect residents from cross contamination of blood-borne pathogens. On 9/4/25 at 7:00 PM Staff 3 (LPN) was observed to check Resident 44’s CBG using a community use glucometer. Staff 3 exited the room and set the glucometer on the cart without cleaning it. At 7:23 PM Staff 3 proceeded to enter Resident 40’s room using the same glucometer. The State Surveyor intervened, and Staff 3 went back to the treatment cart and used and EPA approved wipe to clean the glucometer. Staff 3 acknowledged she did not clean the community use glucometer between resident use and stated she usually cleans the glucometer but “it slipped my mind. On 9/4/25 at 8:11 PM Staff 2 (DNS) stated staff were expected to clean community use glucometers using EPA approved wipes and ensure the two-minute dwell time was reached in between resident use. 3. During 9/2/25 lunch meal service, the following was observed on the Northwest unit hallway: -On 9/2/25 at 12:00 PM Staff 8 (NA) carried a tray with partially eaten food out of room [ROOM NUMBER] and then delivered a tray to room [ROOM NUMBER] without completing hand hygiene. -On 9/2/25 at 12:03 PM Staff 8 left room [ROOM NUMBER] and delivered a tray to room [ROOM NUMBER] without completing hand hygiene. -On 9/2/25 at 12:04 PM Staff 8 left room [ROOM NUMBER] and passed a drink to a family member of a resident in room [ROOM NUMBER] without completing hand hygiene. On 9/2/25 at 12:10 Staff 8 stated they did not perform hand hygiene after leaving resident rooms during meal service. On 9/5/25 at 12:19 PM Staff 5 (LPN Resident Care Manager) stated staff were expected to perform hand hygiene after leaving a resident room during meal service.

Aug 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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Based on interview and record review it was determined the facility failed to ensure staff followed the care plan related to toileting for 1 of 1 sampled resident (#7) reviewed for accidents. This placed residents at risk for injuries. Findings include:Resident 7 was admitted to the facility in 9/2015 with diagnoses including multiple sclerosis and overactive bladder.The 5/15/25 Quarterly MDS revealed Resident 7 had a BIMS score of 15, which indicated the resident was cognitively intact, and dependent for toilet hygiene.A review of the 9/14/24 Care Plan revealed Resident 7 required two-person assistance for toileting.A 2/4/25 facility investigation revealed Resident 7 fell out of bed when Staff 5 (Agency CNA) was providing toileting care and did not have a second person assisting.On 8/25/25 at 12:12 PM Resident 7 stated the staff member rolled her/him off the bed while providing care because the CNA stated she could provide the care herself and did not need another person to assist.On 8/28/25 at 1:16 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Resident 7's care was not followed when the fall occurred.

Feb 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0661 (Tag F0661)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined the facility failed to complete a discharge summary which included a recapitulation of stay and a final summary of the resident's status for 1 of 3 sampled residents (#1) reviewed for a discharge summary. This placed residents at risk for unmet needs post discharge. Findings include: Resident 1 admitted to the facility in 4/2024, with diagnoses including hip fracture and congestive heart failure. On 7/1/24, the State Agency received a public complaint which alleged Resident 1 was discharged home and the facility did not refer Resident 1 to her/his long standing home health agency. Witness 1 (Complainant) stated she made multiple phone calls to the facility in order to ensure Resident 1 received continuity of care with her/his home health agency upon her/his discharge. Witness 1 stated the facility referred Resident 1 to a different home health agency and the other home health agency never made a home visit. Review of the Discharge summary dated [DATE] revealed that Resident 1 was discharged home. The Discharge Summary did not include a nursing or physician recapitulation of Resident 1's diagnosis, course of illness or treatment at the facility, pertinent home health agency or contact information, prognosis or condition on discharge. On 2/12/25 at 11:02 AM, Staff 3 (Social Services Director) stated it was an expectation that a resident discharge summary contain information about resident diagnoses, course of illness or treatment at the facility, prognosis or condition on discharge and home health agency and contact information. She further stated the facility typically referred discharged residents to their previous home health agency unless the agency was unable to resume services.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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Based on interview and record review it was determined the facility failed to follow physician orders for 1 of 3 sampled residents (#4) reviewed for medication administration. This placed residents at risk for unmet medication needs. Findings include: Resident 4 admitted to the facility in 8/2024, with diagnoses including End Stage Renal Disease (ESRD) and clavicle fracture. Resident 4's initial care plan dated 8/24/24 revealed she/he received medications for pain and End Stage Renal Disease and attended dialysis two times per week. Physician orders dated 8/24/24 revealed Resident 4 was to receive Gabapentin (a medication for nerve pain), 100 mg capsule TID, and Sodium Zirconium Cyclosilicate, 1 packet QD for hyperkalemia (a condition where the potassium level in the blood is too high) on the resident's non dialysis days. Review of Resident 4's 9/2024 MAR revealed she/he was not administered Sodium Zirconium Cyclosilicate on 9/12/24 and 9/14/24 and was not administered Gabapentin on 9/24/24, 9/25/24 and 9/26/24. Progress notes reviewed from 9/12/24 through 9/26/24 did not provide an explanation as to why the medication was not administered. On 2/14/25 at 1:00 PM, Staff 1 (Administrator) and Staff 2 (DNS) were notified of the investigative findings regarding missed medications and provided no additional information.

May 2024 14 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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Based on interview and record review it was determined the facility failed to ensure a resident was treated in a dignified manner for 1 of 4 sampled residents (#114) reviewed for dignity. This placed residents at risk for lessened quality of life. Findings include: Resident 114 was admitted to the facility on 2/2024 with diagnoses including end stage renal disease and depression. A 3/20/24 Mistreatment Investigation revealed the following: * Staff 2 (DNS) was informed on 2/27/24 Resident 114 had a concern regarding her/his care. Staff 2 spoke with Resident 114, who indicated the incident occurred roughly one week prior. During the night shift, a female staff member entered the resident's room because she/he had a bowel movement in bed. The staff person stated, Oh, you shit the bed. Resident 114 did not feel abused, but stated the staff person was rude. Resident 114 stated other staff assisted with cleaning her/him up. *Staff 2 determined Staff 26 (Former RN) worked with Resident 114 on 2/19/24 during the night of the incident. *Staff 26 recalled the incident and stated Resident 114 had a bowel movement, and poop was everywhere. Staff 26 denied making a derogatory comment towards Resident 114. Staff 26 stated she had a CNA and another nurse provide ADL care and clean the bed/bedding. Resident 114 was assisted back to bed. *Staff 21 (LPN) reported Staff 26 worked the night shift on 2/19/24. While the CNA assigned to Resident 114 was on break, Resident 114's roommate peaked her/his head out and indicated they needed help in the room. Staff 26 went into the room and immediately came back to the nurses' station and stated, [She/He] shit everywhere, [she/he's] wiping it everywhere. Staff 26 asked Staff 21 to assist in cleaning Resident 114 up. The bedding was changed, and Resident 114 received a shower before being situated back in bed. *Conclusion: Mistreatment was ruled out. Staff 26 provided all necessary cares at the time of the incident and denied speaking to Resident 114 in the alleged manner. No other resident concerns were reported. Staff 26 received education regarding customer service in the workplace. On 5/13/24 at 2:07 PM Witness 1 (Complainant) stated Resident 114 reported a bowel incident which occurred roughly in the middle of 2/2024. Witness 1 stated during the night, Resident 114 had a bowel movement, and a staff person entered the resident's room, saying, You shit all over yourself and the bed. Witness 1 stated Resident 114 was embarrassed and did not want to talk about the incident. Witness 1 stated the facility investigated the incident but Witness 1 was unsure of the outcome. On 5/14/24 at 10:57 AM Resident 114 stated she/he recalled the incident, which happened during night shift. Resident 114 stated she/he had an accident (bowel movement) in bed. Staff 26 entered her/his room and stated, You shit all over the place. Resident 114 stated Staff 26 berated her/him and the incident was embarrassing. Resident 114 stated two other staff members assisted in cleaning her/him up. Attempts were made on 5/15/24 and 5/16/24 to reach Staff 26, but were unsuccessful. On 5/16/24 at 2:25 PM Staff 21 (LPN) stated she recalled the incident on 2/19/24 with Resident 114. Staff 26 approached the nurses' station and reported the resident, had shit everywhere. Staff 21 stated she and another CNA, along with Staff 26, cleaned up the resident and her/his bedding. On 5/17/24 at 2:50 PM Staff 2 (DNS) stated she initiated and completed the investigation. Staff 26 denied she made derogatory comments towards Resident 114 and assisted in cleaning her/him. Staff 2 stated education was provided to Staff 26, and she did not return to the building after the 2/19/24 incident. On 3/3/24, the Past Noncompliance was corrected when the facility completed the following: 1. Performed a thorough investigation of the incident and submitted a FRI on 2/27/24. 2. Interviewed Resident 114 and other residents in the facility and asked about care concerns. 3. Interviewed staff involved in the incident. 4. Educated Staff 26 and she did not return or work for the facility after 2/19/24 incident.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0554 (Tag F0554)

Could have caused harm · This affected 1 resident

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2. Resident 26 was admitted to the facility in 1/2024 with diagnoses including paraplegia. The 1/15/24 admission MDS revealed Resident 26 was cognitively intact. On 5/17/24 at 10:42 AM Resident 26 stated she/he kept a prescription medication, ipratropium bromide nasal spray (used for rhinitis), at her/his bedside in a locked box. Resident 26's comprehensive care plan, last revised on 3/25/24, revealed the resident self-administered certain prescription medications including ipratropium bromide nasal spray. A review of Resident 26's health record indicated a self-administration of medication evaluation was completed on 2/23/24, however, Resident 26 was not assessed to self-administer ipratropium bromide nasal spray. On 5/17/24 at 11:14 AM Staff 36 (Agency RN) stated Resident 26 had self-administered ipratropium bromide nasal spray and reported to the charge nurse when she/he self-administered the medication and if the dose was effective. Staff 36 stated he then documented in the resident's medical record of the administration and the result. On 5/20/24 at 1:57 PM Staff 12 (LPN Resident Care Manager) confirmed the resident was not assessed to self-administer ipratropium bromide nasal spray. Based on observation, interview and record review it was determined the facility failed to assess self-administration of a medication for 2 of 3 sampled residents (#s 8 and 26) reviewed for self-administration of medication. This placed residents at risk for unsafe medication administration. Findings include: The facility's Self-Administration Medication policy last revised on 3/2020, specified the following: -Upon admission the resident's desire to self-administer is ascertained. -During the 14-day admission assessment period the RCM (Resident Care Manager) evaluates the resident's ability to self-administer medications. -If the resident has the cognitive, physical, and emotional ability to self-administer their own medications in a safe and prudent manner a plan for self-administration is established with the resident. -A physician order is obtained indicating the specific medications that the resident is able to self-administer. -The self-administration is on the resident's care plan to include location of drugs, documentation procedure, place of administration and specific medications. -The resident is reevaluated for continued ability to self-administer their medications annually and with significant change in condition. 1. Resident 8 was admitted to the facility in 4/2024 with diagnoses including a stroke and heart disease. A Physician Order dated 4/29/24 revealed Resident 8 was to receive Artificial Tears ophthalmic solution and to instill one drop in both eyes as needed for dry eyes daily. A 4/30/24 admission MDS indicated Resident 8 had a BIMS score of 14 and she/he was cognitively intact. A review of Resident 8's clinical record revealed no evidence that a self-administration of medication assessment was completed. Random observations from 5/13/24 through 5/16/24 revealed Resident 8 was in bed, and a small green bottle labeled Artificial Tears was on her/his bedside table. On 5/14/24 at 10:40 AM Resident 8 stated the eye drops were for her/his eyes and she/he self-administered the eye drops. On 5/16/24 at 11:42 AM Staff 6 (CNA) stated Resident 8 was confused at baseline. Staff 6 stated she did not notice the eyedrops on the resident's bedside table, but Resident 8 required assistance from a nurse in administering the eye drops. On 5/16/24 at 2:39 PM and 3:20 PM Staff 12 (LPN-Resident Care Manager) stated she was unaware Resident 8 had eye drops accessible at her/his bedside table and thought maybe a family member brought the eye drops in. Staff 12 removed the eye drops from the resident's bedside table. Staff 12 stated the resident was not to self-administer eye drops unless a self-medication assessment was completed.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0557 (Tag F0557)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 20 was admitted to the facility in 2020 with diagnoses including depression and anxiety. The 4/2/24 Annual MDS indicated Resident 20 was cognitively intact. On 5/14/24 at 2:43 PM during a resident group meeting, respect of resident's personal possessions was discussed. Resident 20 stated she/he submitted a grievance form in 3/2024 regarding missing and broken personal property, but was not reimbursed. On 5/15/24 at 11:34 AM two submitted grievance forms, dated 3/21/24, were reviewed. One grievance form indicated the resident was missing several clothing items. The second grievance form indicated a staff member pulled down and damaged hanging lights in the resident's room. Both grievance forms indicated a reimbursement was approved by Staff 1 (Administrator) on 3/25/24. A copy of the receipt for reimbursement was requested on 5/15/24 by the survey team. On 5/16/24 at 11:00 AM two cash disbursement vouchers were provided and revealed a cash reimbursement for Resident 20's missing clothing and broken personal property was issued on 5/15/24. On 5/16/24 at 3:04 PM Staff 3 (Corporate Social Service Director) confirmed the resident's request for reimbursement for personal possessions was not completed timely. Based on observation, interview and record review it was determined the facility failed to ensure resident personal property was identified upon admission, and clothing was retained and accessible for 2 of 4 sampled residents (#s 20 and 57) reviewed for personal property. This place residents at risk for loss of personal property. Findings include: The facility's Resident Personal Items Safekeeping policy, last revised 4/2023, specified the following: -All personal items, including but not limited to clothing, dentures, glasses, and hearing aids must be marked with the resident's name upon admission. -The facility designee will assist residents and families with marking the personal belongings. -On admission and thereafter each time a resident's personal possession is brought into the facility, the item will be recorded on the resident's inventory record by designated staff and signed by the resident or responsible party. -If any personal items is lost during a resident's stay, an investigation will be completed by the facility and the results will be communicated to the resident and/or family. -The Administrator/designee will discuss the method of replacement for lost items with the resident and/or family. 1. Resident 57 was admitted to the facility in 4/2024 with diagnoses including chronic heart failure and diabetes. The Annual MDS dated [DATE] revealed Resident 57 had a BIMS score of 15 and was cognitively intact. Resident 57's Inventory Record dated 4/19/24 revealed the resident had one pair of black shoes, navy blue sleeping shorts, a black pair of slacks and a black t-shirt. On 5/13/24 at 11:40 AM, the resident was observed in bed wearing a facility nightgown. Resident 57 stated she/he wanted to be dressed in her/his own clothing but it was hit or miss if this was offered by staff. The resident stated she/he was uncertain of the location of her/his clothes. Random observations from 5/14/24 through 5/17/24 revealed Resident 57 was either in bed wearing a facility nightgown or in bed with no nightgown on, with her/his chest exposed. On 5/14/24 at 7:22 PM Staff 15 (CNA) and on 5/16/24 at 12:53 PM Staff 14 (CNA) stated Resident 57 requested to be dressed, but the resident did not have appropriate clothing to wear. Staff 14 and Staff 15 were unsure where the resident's clothes were, which was why Resident 57 was consistently in her/his nightgown. Staff 15 stated he reported the resident's lack of clothing to a nurse. On 5/17/24 at 4:01 PM Staff 9 (RNCM) entered the room with the surveyor and located Resident 57's black shoes, a pair of shorts and a black jacket. None of the items had Resident 57's name on them. Staff 9 reviewed Resident 57's Inventory Record and acknowledged the resident admitted with a pair of slacks and a T-shirt, which were not found in her/his room. Staff 9 stated no missing form was completed or missing items were reported to her regarding Reident 57's missing clothing items. Staff 9 stated Resident 57's clothing items were to be labeled, and any missing clothing items were to be reported. Staff 9 further stated the resident was to be dressed per her/his request.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

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Based on interview and record review it was determined 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 2 of 3 sampled residents (#s 4 and 44) reviewed for care planning. This placed residents at risk for being uninformed about their plan of care. Findings include: 1. Resident 4 was admitted to the facility in 2022 with diagnoses including paralysis of left side and osteoporosis. On 5/14/24 Resident 4's clinical record was reviewed. No record was found that Resident 4 had a baseline care plan reviewed or provided to her/him. On 5/16/24 at 12:33 PM Staff 3 (Corporate SSD) confirmed no baseline care plan was discussed or provided to Resident 4. 2. Resident 44 was admitted to the facility in 2/2024 with diagnoses including heart failure and chronic kidney disease. Resident 44's 2/2024 admission MDS indicated she/he was cognitively intact. On 5/14/24 Resident 44's clinical record was reviewed. No record was found that Resident 44 had a baseline care plan reviewed or provided to her/him. On 5/16/24 at 12:33 PM Staff 3 (Corporate SSD) confirmed no baseline care plan was discussed or provided to Resident 44.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to follow physician orders and provide bowel medication in a timely manner for 1 of 6 sampled residents (#57) reviewed for medications. This placed residents at risk for medical complications from constipation. Findings include: The facility's Bowel Care Protocol Policy last revised on 2/2019, specified the following: -At beginning of each shift the nurse will pull the bowel care report and identify residents that have not had a BM (Bowel Movement) for 3 days. -Residents who have not had a BM in three days will be given MOM (Milk of Magnesia). -If no BM by the following shift, a Dulcolax suppository is given. -If resident continues without BM by the next shift a Fleets enema will be given. -Residents who are noted as having small bowel movement will be assessed for constipation. -If resident exceeds four days without a BM, the nurse will complete an abdominal assessment and the physician will be notified for further orders. Resident 57 was admitted to the facility in 4/2024 with diagnoses including chronic heart failure and diabetes. Resident 57's BM documentation from 4/19/24 through 5/9/24 revealed the following: -4/26/24 through 5/1/24 (six days) Resident 57 did not have a BM. -5/3/24 through 5/8/24 (six days) Resident 57 did not have a BM. Resident 57's Physician Order Report signed by the physician on 4/22/24 included an order for polyethylene glycol packet. Staff were to administer 17 grams by mouth one time daily as needed for bowel care. Resident 57's 5/2024 MAR revealed the polyethylene glycol packet was administered on 5/8/24 and was marked as U (unknown). A Nutrition assessment dated [DATE] revealed Resident 57 had constipation and was placed on the bowel protocol with no BM for the prior week. Resident 57 had a large BM on 5/9/24. A review of the resident's clinical record revealed no documentation bowel care was implemented timely or an abdominal assessment was completed. On 5/16/24 at 10:53 AM Staff 4 (LPN) stated Resident 57 struggled with constipation and was frequently on the bowel list. Staff 4 stated she followed bowel protocol: if Resident 57 had no BM after three days, the resident was administered MiraLAX (a laxative) during the morning shift. If there was still no BM by the following shift, the resident received Senna (a laxative). If these measures yielded no results, Staff 4 stated she contacted the provider for a possible enema. On 5/17/24 at 4:01 PM Staff 9 (RNCM) stated Resident 57 had problems with BMs and was frequently on the bowel list. Staff 9 stated residents did not have standing PRN bowel orders and depended on the doctor. Staff 9 acknowledged the findings and stated Resident 57's bowel protocol needed to be initiated due to her/his constipation. On 5/20/24 at 1:13 PM Staff 2 (DNS) stated staff were expected to implement and adhere to the bowel protocol. Additionally, if a resident had no BM by day four staff were to contact the physician and conduct a bowel assessment.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0687 (Tag F0687)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 26 was admitted to the facility in 1/2024 with diagnoses including paraplegia. The 1/15/24 admission MDS revealed Resident 26 was cognitively intact. On 5/13/24 at 2:18 PM Resident 26 stated her/his toenails were long, thick, and caught on the inside of her/his socks. Resident 26 stated she/he wanted her/his toenails trimmed and voiced her/his concern to staff, but no one followed up with her/him. Resident 26's toenails were observed to be long in length, thick, fungal, and jagged. On 5/16/24 at 10:34 AM Resident 26 stated she/he had a bath on 5/15/24 and requested her/his toenails to be trimmed or at least filed and the CNA stated they would let the nurse know. The resident stated the nurse did not talk with her/him. On 5/16/24 at 11:16 AM Staff 12 (LPN Resident Care Manager) stated toenail care was provided on bath days for the resident and Staff 12 expected it to be completed. On 5/16/24 at 2:57 PM Staff 3 (Corporate Social Services Director) stated the facility had a podiatrist that rounded every three months and podiatry services were offered to all residents. Staff 3 stated the podiatrist could not see every resident on the list, so a rotation was completed. Staff 3 stated Resident 26 was on the podiatrist's list to be seen on the next rotation. Based on observation, interview and record review it was determined the facility failed to provide appropriate foot care for 3 of 3 sampled residents (#s 26, 41 and 57) reviewed for foot care. This placed residents at risk for lack of nail care and infections. Findings include: 1. Resident 41 was admitted to the facility on 3/2024 with diagnoses including diabetes. A Physician Order dated 3/27/24 directed a licensed nurse to check Resident 41's fingernails and toenails once a week on bath day. The order indicated to trim as needed every day shift on Wednesdays for diabetic nail checks. Staff were directed to document (+) if the nails were trimmed and (-) if nail trimming was not needed. A review of the LN Task from 3/2024 through 5/2024 revealed the following: -3/27/24 nails did not need trimmed. -4/3/24, 4/10/24 and 4/17/24 nails did not need trimmed. 4/24/24 Resident 41 refused nail care. -5/1/24 nails did not need trimmed. 5/8/24 Resident 41 refused nail care. A Progress Note dated 5/9/24 revealed Staff 9 (RNCM) entered Resident 41's room to offer toenail care. Resident 41 initially stated she would allow toenail care without clippers only for toenails to be filed down. Resident 41 allowed Staff 9 to file three out of 10 toenails and then declined to have the rest of the toenails trimmed. On 5/13/24 at 10:44 AM Resident 41 stated she/he was a diabetic for 40 years and needed her/his toenails treated by a podiatrist which was not scheduled. Resident 41 indicated staff were unable to cut her/his thick toenails and made her/him uncomfortable when staff attempted to complete the nail care. Random observations from 5/13/24 through 5/16/24 revealed Resident 41 was in bed and her/his toes were observed with all toenails discolored, deformed, thickened (half-an-inch) and longer than one inch. Resident 41's right large toenail was brownish/black. On 5/14/24 at 6:46 PM Staff 32 (CNA) and on 5/16/24 at 11:42 AM Staff 6 (CNA) entered the room with the surveyor and acknowledged Resident 41's toenails were long, thick, discolored and indicated the toenails were, awful. Staff 32 stated she noticed the resident's long and discolored toenails. Staff 6 stated nail care was provided by the nursing staff because Resident 41 was diabetic. Staff 6 and Staff 32 stated the resident occasionally declined showers due to anxiety but accepted a bed bath. On 5/16/24 at 9:47 AM Staff 11 (LPN) stated nurses were responsible for diabetic nail care. Staff 11 stated Resident 41's toenails were thick, long, and difficult to trim and needed to be addressed. Staff 11 stated nurses completed weekly skin checks which included observing finger and toenails. On 5/16/24 at 2:54 PM Staff 9 (RNCM) stated nurses were expected to complete nail care for diabetic residents. Staff 9 stated Resident 41 was a brittle diabetic, who occasionally declined nail care. Staff 9 stated she attempted to file Resident 41's toenails but the resident did not allow Staff 9 to complete the task. When asked about a podiatry appointment, Staff 9 stated LTC (Long Term Care) residents were placed on the in-house podiatry list. Staff 9 stated the care managers assisted with appointments, including podiatry outside of the facility. 2. Resident 57 was admitted to the facility in 4/2024 with diagnoses including chronic heart failure and diabetes. The Annual MDS dated [DATE] revealed Resident 57 had a BIMS score of 15 and was cognitively intact. A Physician Order dated 4/24/24 directed a licensed nurse to check fingernails and toenails once a week on bath day. The order indicated to trim as needed every day shift every Wednesday for diabetic nail checks. Staff were directed to document (+) if nails were trimmed and (-) if nail trimming was not needed. A review of the LN Task from 4/2024 through 5/2024 revealed the following: - On 4/24/24, 5/1/24, 5/8/24 and 5/15/24 nails did not need trimmed. On 5/13/24 at 11:40 AM and 5/16/24 at 11:16 AM the resident stated her/his toenails were long, thick, and needed to be trimmed. Random observations from 5/13/24 through 5/16/24 revealed Resident 57 was in bed and her/his toes were observed with all toenails longer than one inch, and his second toenails were deformed, thickened (half-an-inch) and discolored. On 5/16/24 at 10:53 AM Staff 4 (LPN) stated Resident 57 was diabetic and nurses were responsible for addressing all nail care. Staff 4 stated she was not sure if the resident's toenails were long, but if she was unable to address Resident 57's nail care then she reported it to the care manager to schedule a podiatry appointment. On 5/16/24 at 2:54 PM and 5/17/24 at 4:01 PM Staff 9 (RNCM) stated nurses were expected to provide nail care for diabetic residents. If staff were unable to perform diabetic nail care, staff were expected to report this to her. Staff 9 entered the room with the surveyor and acknowledged Resident 57's toenails were long and were not treated appropriately.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined the facility failed to ensure interventions were in place to prevent smoking related accidents for 1 of 2 sampled residents (#32) reviewed for accidents. This placed residents at risk for smoking-related accidents. Findings include: The facility's 10/2023 Smoking Policy and Procedure indicated the following: -Residents who wish to smoke are evaluated for their ability to smoke safely. A smoking evaluation is completed at admission or at the time they decided to smoke, to evaluate their ability to smoke safely. -Definition of Smoking Materials: Cigarettes, Cigars, Pipes, Novelties - E-Cigarettes, Vapor Devices, Ignition Sources. -Residents who do not adhere to the smoking policies are subject to revocation of their ability to smoke while a resident at the facility. Resident 32 admitted to the facility on [DATE] with diagnoses including right lower extremity cellulitis and diabetes. A 4/28/24 progress note revealed a fire alarm was triggered when Resident 32 stated she/he burned papers in her/his room which caused the room to fill with smoke and Resident 32 was found in possession of a torch lighter. A 5/9/24 progress note revealed Resident 32 was smoking in her/his room. Staff reviewed the smoking policy with the resident. Lighters and smoking materials were removed from the resident's room. Resident 32's smoking care plan was initiated on 5/13/24 which revealed the resident was an unsupervised smoker. The care plan did not include safe storage of the smoking paraphernalia and interventions to regarding previous smoking incidents that occurred in the resident's room. On 5/15/24 at 10:36 AM Staff 28 (CNA) stated Resident 32 was a smoker who smoked in her/his room and did not smoke in the designated smoking area. Staff 28 stated Resident 32 was supposed to keep her/his smoking paraphernalia in a lockbox in her/his room. On 5/16/24 at 10:59 AM Resident 32 was observed seated at the edge of the bed with a four-inch green tubular-shaped canister with a pink bejeweled handle. Resident 32 stated it was her/his blow torch lighter and demonstrated that the lighter was operational. Resident 32 stated the facility kept taking her/his lighters and she/he kept replacing them. Resident 32 stated she/he was allowed to keep lighters in her/his lockbox. On 5/16/24 at 1:40 PM Staff 23 (CMA) stated she had seen Resident 32 with smoking paraphernalia in her/his room but was not sure what rules Resident 32 was supposed to follow. Staff 23 stated Resident 32 had been caught smoking in her/his room several times but was still allowed to keep her/his smoking paraphernalia in her/his room. Staff 23 stated she informed the charge nurse of the smoking paraphernalia. On 5/16/24 at 3:06 PM Staff 35 (LPN) stated she considered Resident 32 a smoker and all her/his smoking paraphernalia including marijuana, cigarettes and lighters were in a lockbox in her/his room. Staff 35 stated Resident 32 had smoking paraphernalia confiscated the previous week due to smoking in her/his room and staff were told to do a visual sweep of Resident 32's room whenever staff went into the resident's room. A SNF Smoking Safety Evaluation completed on 5/16/24 revealed Resident 32 was a supervised smoker, was not receptive to supervision, was unwilling to store her/his smoking items with the facility and continued to make unsafe smoking choices. On 5/20/24 at 10:42 AM Staff 2 (DNS) acknowledged the safety concerns associated with Resident 32's possession of incendiary devices in the facility, and history of unsafe behaviors including smoking in her/his room. Staff 2 acknowledged a smoking assessment was not completed until 5/16/24, and the care plan was not updated regarding the safety concerns.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review it was determined the facility failed to maintain oxygen equipment and ensure oxygen was administered as ordered for 1 of 2 sampled residents (#46) reviewed for oxygen therapy. This placed residents at risk for increased risk for respiratory failure. Findings include: Resident 46 was admitted to the facility in 2/2024 with diagnoses including acute and chronic respiratory failure with hypoxia (not enough oxygen in the blood) and hypercapnia (buildup of carbon dioxide in the bloodstream). The 2/9/24 admission MDS indicated Resident 46 was cognitively intact. The 5/13/24 physician order for Resident 46 revealed the resident used continuous oxygen with a flow rate of two liters since 4/25/24. On 5/13/24 at 12:04 PM Resident 46 was observed to use an oxygen concentrator with a flow rate of three liters. The external filter on the oxygen concentrator was observed to have a layer of dust when touched with a finger. The resident stated she/he used oxygen most of the time but could not state how many liters were prescribed. On 5/16/24 at 11:21 AM Staff 12 (LPN Resident Care Manager) observed the resident and equipment. Staff 12 acknowledged the physician's order was not followed regarding the oxygen flow rate and the external filter of the oxygen concentrator was not clean.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to ensure a resident's ordered pain medication was available and effectively managed the resident's severe pain for 1 of 1 sampled resident (#36) reviewed for pain management. This failure placed residents at risk for unrelieved pain. Findings include: Resident 36 was admitted to the facility in 9/2023 with diagnoses including rheumatoid arthritis, a fractured tibia and polyneuropathy (nerve pain). A Physician Order dated [DATE] directed staff to administer Percocet (pain medication), one tablet 10-325 MG (oxycodone with acetaminophen) by mouth six times a day related to displaced bicondylar fracture of the right tibia. Resident 36's 5/2024 MAR revealed the resident was administered Percocet on [DATE] at 2:00 AM. The resident was not administered Percocet on [DATE] at 6:00 AM, 10:00 AM or 2:00 PM. A Physician Order dated [DATE] directed staff to administer oxycodone 10 MG with 325 MG Tylenol, one tablet by mouth one time only for pain. Resident 36's 5/2024 MAR revealed the resident was administered a one time oxycodone dose on [DATE] at 1:20 PM. Resident 36 did not receive her/his pain medication on [DATE] for 11 hours and 20 minutes. A review of Resident 36's pain levels from a scale of zero through 10 (zero no pain and 10 being the worst pain possible) on [DATE] and [DATE] revealed the following: *[DATE] the resident did not report any pain. *[DATE] at 2:52 PM the resident reported a pain level of six. *[DATE] at 6:02 PM the resident reported a pain level of nine. *[DATE] at 9:13 PM the resident reported a pain level of six. On [DATE] at 11:18 AM and at 12:30 PM Resident 36 was observed in bed, lying on her/his right side facing away from the door, and rocking back and forth in bed. Resident 36 stated she/he was painful and very uncomfortable because she/he did not receive the scheduled Percocet since 3:00 AM. Resident 36 stated the facility staff were working on obtaining the medication. On [DATE] at 9:37 AM Staff 11 (LPN) stated the night shift nurse administered Resident 36's last dose of scheduled Percocet in the early AM hours on [DATE] and placed a call to the in-house physician for a new prescription because the Percocet prescription expired. Staff 11 stated the resident received a one time dose at approximately 1:30 PM. Staff 11 stated she offered ice or heat packs for the resident's pain, but she/he declined. Staff 11 stated Resident 36 was grimacing when up in her/his wheelchair. Staff 11 stated CMAs typically reordered medications, including if a resident needed a new prescription. On [DATE] at 11:42 Staff 6 (CNA) stated on [DATE] (Monday), Resident 36 was in her/his room, in bed and rocking back and forth due to pain. Staff 6 stated the resident was visibly painful, was less verbal and did not eat breakfast. Staff 6 stated the resident expressed frustration because the facility was out of her/his pain medication. Staff 6 reported her concern to the nurse. On [DATE] at 1:15 PM Staff 10 (LPN) stated he administered the last Percocet to Resident 36 in the early morning on [DATE]. However, Staff 10 could not access the Cubex (an automated medication dispensing system) because the resident's prescription was expired and he communicated this with the oncoming nurse. Staff 10 contacted the in-house physician to request a new prescription. Staff 10 stated CMAs were responsible for ensuring timely medication reorders were completed. Staff 10 stated CMAs were expected to request refills when there were only seven days of medication remaining in the prescription. On [DATE] at 11:03 AM Staff 5 (CMA) stated Resident 36 received Percocet every four hours. Staff 5 stated she was responsible for ensuring residents' medications did not run out. Staff 5 stated when the resident had only four tablets remaining, she requested additional medication through the electronic record which went directly to the pharmacy. Staff 5 stated if a prescription was expired, she reported it to a nurse, who contacted the physician to request a new prescription. On [DATE] at 3:46 PM Staff 9 (RNCM) stated she was aware Resident 36 ran out of her/his Percocet. The resident was in pain, and it was unclear why the one time dose took so long to be received. Staff 9 stated on [DATE] Resident 36 was in her/his doorway, appeared anxious, and in pain. Resident 36 requested Staff 9's assistance in obtaining her/his pain medication. Staff 9 stated Resident 36 should not have run out of her/his pain medication and staff were to request new refills three days prior to running out. On [DATE] at 1:19 PM Staff 2 (DNS) acknowledged Resident 36's Percocet was not administered on [DATE] per physician orders. Staff 2 stated nonpharmacological pain interventions were offered to the resident until staff could address the situation. Staff 2 stated CMAs were responsible for ensuring medications were ordered for all residents and prescriptions did not expire. Staff 2 stated somehow Resident 36's medications were overlooked.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0742 (Tag F0742)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined the facility failed to provide person-centered approaches to behavioral symptoms for 1 of 2 sampled residents (#32) reviewed for psychosocial well-being. This placed residents at risk for unmet psychosocial and mental health needs. Findings include: Resident 32 admitted to the facility on [DATE] with diagnoses including right lower extremity cellulitis and diabetes. The resident did not have a documented diagnosis related to mental health or trauma at the time of admission. A 3/22/24 psychiatric consultation note stated Resident 32 was, labile, cycling through post traumatic memories of fighting in the war with very graphic, disturbing traumatic content, despondent memories and escalating despair. The note recommended Resident 32 continue with psychotherapy treatments. A 4/3/24 physician visit note revealed Resident 32 was distressed from experiences with her/his time in the war. On 5/15/24 at 10:36 AM Staff 28 (CNA) stated Resident 32's behaviors included talking to herself/himself about the war, keeping the curtain drawn, startling easily and overreacting at times when startled. On 5/16/24 at 10:59 AM was observed Resident 32 pacing in her/his room while appearing to talk to herself/himself and rubbing her/his head. Resident 32 stated her/his had was not good as a result of her/his experiences in war. Resident 32 recalled a mental health consult around the time of admission and stated she/he would continue to see someone for her/his mental health if offered. On 5/17/24 at 3:12 PM Staff 9 (RNCM) stated a psychiatric consult was requested for Resident 32 at the time of admission because the resident expressed concerns regarding post-traumatic stress disorder (PTSD). A review of Resident 32's clinical record on 5/17/24 revealed no care planned intervention to address Resident 32's mental health needs, and no indication the resident received follow-up treatment related to mental health needs since the 3/22/24 psychiatric consultation. On 5/17/24 at 3:17 PM Staff 37 (LPN Resident Care Manager) acknowledged there was no evidence to indicate Resident 32 received mental health treatment since the 3/22/24 psychiatric consultation. On 5/20/24 at Staff 2 (DNS) acknowledged Resident 32 did not have any follow-up mental health treatment after the initial consultation and the resident's care plan was not updated to reflect the resident's mental health needs and interventions.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on observation and interview it was determined the facility failed to ensure proper labeling of biologicals for 1 of 2 medication rooms reviewed for medication storage. This placed residents at risk for reduced efficacy of medication. Findings include: According to the Center for Disease Control and Prevention: Multi-Dose Vial Safety Reminders (2023): -When you first put a clean needle in the vial, write the date and time on the label. -The beyond-use-date refers to the date after which an opened multi-dose vial should not be used. The vial should be discarded within 28 days of the opened date. On 5/20/24 at 12:40 PM during a review of station one medication storage room with Staff 2 (DNS), one vial of lidocaine solution was observed to be opened with no open date. The vial indicated it was a multiple dose vial. On 5/20/24 at 12:44 PM Staff 2 acknowledged the vial of lidocaine solution was opened and not labeled with an open date.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review it was determined the facility failed to protect resident identifiable information and ensure records were accurate for 2 of 4 sampled residents (#s 41 and 42) reviewed for record management and insulin. This placed residents at risk for unauthorized use of their personal information and inaccurate treatment. Findings include: 1. A review of the facility's 12/2023 HIPAA (Health Insurance Portability and Accountability Act) Compliance policy indicated the facility was to safeguard all forms of PHI (Protected Health Information) for each resident. On 5/17/24 at 12:33 PM resident identifiable information including Resident 41's name, medication type, prescription number, and the resident's physician's name was observed inside a clear plastic garbage bag with no lid located on the side of a nurse treatment cart. The treatment cart was in the hallway close to the front entrance of the facility and available for anyone in the facility to see. Other items observed in the garbage bag with the resident identifiable information included used gloves and an opened alcohol wipe packet. On 5/17/24 at 12:36 PM Staff 27 (Corporate RN) acknowledged the garbage bag contained resident identifiable information and further acknowledged resident identifiable information was not to be placed in any garbage. Staff 27 stated the expectation was for staff to place any resident identifiable information in a secure confidential shred bin located inside the facility. 2. Resident 42 was admitted 2/2024 with a diagnosis of Type 1 Diabetes. A 3/5/24 Significant Change of Condition MDS indicated Resident 42 was cognitively intact. a. The 3/11/24 at 9:48 AM progress note indicated Resident 42 was Hypoglycemic with glucose readings of 61 and 91 before breakfast. Post breakfast it was reported to the licensed nurse that Resident 42 refused breakfast, had a blood glucose level of 37, was diaphoretic and was arousable but was not completely conscious or awake. The Licensed Nurse documented giving 15oz of juice, an intramuscular shot of glucagon, and gel applied to gums (a substitute for oral tablets when swallowing capability is in question). The 3/2024 Diabetic administration record indicated the Glucagon emergency kit, Glucose Oral tablet Chewable 4gm (to be given if blood glucose reading was below 70), and the Hypoglycemia protocol (to be initiated for a blood glucose reading below 70 and patient is showing symptoms) was not administered. On 5/17/24 at 10:17 AM Staff 2 (DNS) stated the progress note which indicated Resident 42's blood glucose reading was 61 before breakfast was incorrect and should not have been in the progress note. Staff 2 stated the actions taken by the licensed nurse in the same progress note were documented correctly. Staff 2 confirmed the diabetic administration record did not show the interventions administered to Resident 42 on 3/11/24. b. The 5/16/24 progress note indicated Resident's blood sugar dropped to 67, [orange juice] given, and provider notified. A review of the 5/2024 Diabetic Administration Record (DAR) revealed the record did not reflect the interventions documented in the progress note. On 5/17/23 at 11:16 AM Staff 33 (LPN) confirmed the DAR did not reflect the actions taken by Staff 34 (LPN) to remedy Resident 42's low blood glucose levels. Staff 33 stated Resident 42 had PRN orders for low blood glucose, and interventions were to be documented in the DAR. On 5/17/24 at 10:17 AM Staff 2 (DNS) was provided with these findings. Staff 2 confirmed the DAR was blank for 5/16/24.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Assessments (Tag F0636)

Could have caused harm · This affected multiple residents

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7. Resident 26 was admitted to the facility in 1/2024 with diagnoses including glaucoma and depression. The 1/15/24 admission MDS indicated Resident 26 had adequate vision and received an antidepressant medication. The CAAs associated with the 1/15/24 MDS revealed the following: -The Visual Function CAA indicated has glaucoma. No further information was provided specific to the resident's current visual functioning, use of visual appliances, or other treatments in place. -The Psychotropic Drug Use CAA indicated takes antidepressants for depression. The CAA did not indicate a description of the problem, causes and contributing factors or how the resident's symptoms manifested or whether the medication was effective. On 5/20/24 at 8:58 AM Staff 16 (MDS Coordinator) stated she was responsible for completing the MDS assessment and CAAs for all residents. Staff 16 stated she worked remotely and reviewed resident electronic medical records to complete the CAA section. On 5/20/24 at 1:13 PM Staff 2 (DNS) stated she was unfamiliar with the process of completing the CAAs. Staff 2 stated Staff 16 was responsible for the MDS and CAA assessments, and there was daily communication regarding residents' assessments. Staff 1 (Administrator) and Staff 2 acknowledged the CAAs were not comprehensive. 8. Resident 52 was admitted to the facility in 4/2024 with diagnoses including depression. The 4/10/24 admission MDS indicated Resident 52 received an antidepressant medication. The Psychotropic Drug Use CAA associated with the 4/10/24 MDS indicated received antidepressant per physicians orders. The CAA did not indicate a description of the problem, causes and contributing factors or how the resident's symptoms manifested or whether the medication was effective. On 5/20/24 at 8:58 AM Staff 16 (MDS Coordinator) stated she was responsible for completing the MDS assessment and CAAs for all residents. Staff 16 stated she worked remotely and reviewed resident electronic medical records to complete the CAA section. On 5/20/24 at 1:13 PM Staff 2 (DNS) stated she was unfamiliar with the process of completing the CAAs. Staff 2 stated Staff 16 was responsible for the MDS and CAA assessments, and there was daily communication regarding residents' assessments. Staff 1 (Administrator) and Staff 2 acknowledged the CAA was not comprehensive. 5. Resident 25 admitted to the facility in 6/2022 with diagnoses including falls and chronic pain syndrome. The 6/20/23 Annual MDS indicated Resident 25 received scheduled and PRN pain medication. The Pain CAA associated with the 6/20/23 MDS indicated Resident 25 had pain that affected sleep, day-to-day activities and almost constant pain. The CAA did not include a location of the pain, how the resident displayed pain symptoms or whether the medications and other pain interventions were effective. On 5/20/24 at 8:58 AM Staff 16 (MDS Coordinator) stated she was responsible for completing the MDS assessment and CAAs for all residents. Staff 16 stated she worked remotely and reviewed resident electronic medical records to complete the CAA section. Staff 16 further stated she communicated as needed with the Resident Care Managers and the IDT (Interdisciplinary Team). On 5/20/24 at 1:13 PM Staff 2 (DNS) stated she was unfamiliar with the process of completing the CAAs. Staff 2 stated Staff 16 was responsible for the MDS and CAA assessments, and there was daily communication regarding residents' assessments. 6. Resident 32 admitted to the facility in 3/2024 with diagnoses including right lower extremity cellulitis and diabetes. The 3/26/24 admission MDS indicated Resident 32 received an antidepressant medication. The Psychotropic Drug Use CAA associated with the 3/26/24 MDS indicated antidepressant use per physician orders. The CAA did not indicate a description of the problem, causes and the contributing factors, how the resident's symptoms manifested, or whether the medication was effective. On 5/20/24 at 8:58 AM Staff 16 (MDS Coordinator) stated she was responsible for completing the MDS assessment and CAAs for all residents. Staff 16 stated she worked remotely and reviewed resident electronic medical records to complete the CAA section. Staff 16 further stated she communicated as needed with the Resident Care Managers and the IDT (Interdisciplinary Team). On 5/20/24 at 1:13 PM Staff 2 (DNS) stated she was unfamiliar with the process of completing the CAAs. Staff 2 stated Staff 16 was responsible for the MDS and CAA assessments, and there was daily communication regarding residents' assessments. Based on interview and record review it was determined the facility failed to comprehensively assess 8 of 14 sampled residents (#s 25, 26, 32, 36, 52, 55, 57 and 114) reviewed for medications, pressure ulcers, ADLs, pain and nutrition. This placed residents at risk for unassessed needs. Findings include: 1. Resident 57 was admitted to the facility on 4/2024 with diagnoses including chronic heart failure and diabetes. The 4/25/24 admission MDS indicated Resident 57 received an antidepressant medication. The Psychotropic Drug Use CAA associated with the 4/25/24 MDS indicated psych meds per physician orders. The CAA did not indicate a description of the problem, causes and contributing factors or how the resident's symptoms manifested or whether the medication was effective. On 5/20/24 at 8:58 AM Staff 16 (MDS Coordinator) stated she was responsible for completing the MDS assessment and CAAs for all residents. Staff 16 stated she worked remotely and reviewed resident electronic medical records to complete the CAA section. On 5/20/24 at 1:13 PM Staff 2 (DNS) stated she was unfamiliar with the process of completing the CAAs. Staff 2 stated Staff 16 was responsible for the MDS and CAA assessments, and there was daily communication regarding residents' assessments. Staff 1 (Administrator) and Staff 2 acknowledged the CAA was not comprehensive. 2. Resident 55 was admitted to the facility on 4/2024 with diagnoses including a Stage 3 (full thickness tissue loss) pressure ulcer to the tailbone. The Pressure Ulcer CAA dated 4/22/24 indicated Resident 55 needs assist with adls and transfers, has pressure injury to buttocks. The CAA did not include a description of the problem, causes and contributing factors, any alternatives discussed or tried or an overall analysis of the pressure ulcer. On 5/20/24 at 8:58 AM Staff 16 (MDS Coordinator) stated she was responsible for completing the MDS assessment and CAAs for all residents. Staff 16 stated she worked remotely and reviewed resident electronic medical records to complete the CAA section. On 5/20/24 at 1:13 PM Staff 2 (DNS) stated she was unfamiliar with the process of completing the CAAs. Staff 2 stated Staff 16 was responsible for the MDS and CAA assessments, and there was daily communication regarding residents' assessments. Staff 1 (Administrator) and Staff 2 acknowledged the CAA was not comprehensive. 3. Resident 36 was admitted to the facility on 9/2022 with diagnoses including arthritis and polyneuropathy (nerve pain). The 11/17/23 Significant Change MDS and the 2/15/25 Quarterly MDS indicated Resident 36 received scheduled and PRN pain medication. The Pain CAA associated with the 11/17/23 MDS indicated no change to plan of care. The CAA did not include a description of, how the resident displayed pain symptoms or whether the medications and any other interventions were effective. On 5/20/24 at 8:58 AM Staff 16 (MDS Coordinator) stated she was responsible for completing the MDS assessment and CAAs for all residents. Staff 16 stated she worked remotely and reviewed resident electronic medical records to complete the CAA section. On 5/20/24 at 1:13 PM Staff 2 (DNS) stated she was unfamiliar with the process of completing the CAAs. Staff 2 stated Staff 16 was responsible for the MDS and CAA assessments, and there was daily communication regarding residents' assessments. Staff 1 (Administrator) and Staff 2 acknowledged the CAA was not comprehensive. 4. Resident 114 was admitted to the facility on 2/2024 with diagnoses including end stage renal disease and depression. The 2/20/24 admission MDS indicated Resident 57 received an antidepressant medication and was occasionally incontinent of urine and frequently incontinent of bowel. The CAAs associated with the 2/20/24 MDS revealed the following: -The Psychotropic Drug Use CAA indicated takes anti-depressants per physician orders. The CAA did not indicate a description of the problem, causes and contributing factors, how the resident's symptoms manifested or whether the medications were effective. -The Urinary Incontinence and Indwelling Catheter CAA indicated has occasional incontinence and requires assistance with toileting. The CAA did not indicate a description of the problem, causes or contributing factors. On 5/20/24 at 8:58 AM Staff 16 (MDS Coordinator) stated she was responsible for completing the MDS assessment and CAAs for all residents. Staff 16 stated she worked remotely and reviewed resident electronic medical records to complete the CAA section. On 5/20/24 at 1:13 PM Staff 2 (DNS) stated she was unfamiliar with the process of completing the CAAs. Staff 2 stated Staff 16 was responsible for the MDS and CAA assessments, and there was daily communication regarding residents' assessments. Staff 1 (Administrator) and Staff 2 acknowledged the CAA was not comprehensive.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0730 (Tag F0730)

Could have caused harm · This affected multiple residents

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Based on interview and record review it was determined the facility failed to ensure CNAs received annual performance reviews for 4 of 5 randomly selected CNAs (#s 15, 23, 24, and 25) reviewed for staff performance reviews. This placed residents at risk for lack of care by competent staff. Findings include: On 5/17/24 at 9:58 AM a review of facility personnel records with Staff 31 (Human Resource Director) indicated the following: - Staff 15 (CNA) was hired on 8/17/22; no annual performance review was completed. - Staff 23 (CMA) was hired on 8/31/20; no annual performance reviews were completed. - Staff 24 (CNA) was hired on 6/16/16; no annual performance reviews were completed. - Staff 25 (CNA) was hired on 4/11/16; no annual performance reviews were completed. On 5/17/24 at 4:04 PM Staff 1 (Administrator) stated it was his expectation the annual performance reviews were completed annually. Staff 1 confirmed the annual performance reviews were not completed for Staff 15, Staff 23, Staff 24, or Staff 25.

Mar 2023 8 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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Based on interview and record review it was determined the facility failed to have a system in place to ensure residents were provided the opportunity to formulate advance directives for 1 of 1 sampled resident (#33) reviewed for advanced directives. This placed residents at risk for not being informed of choices regarding health care decisions. Findings include: Resident 33 was admitted to the facility in 2020 with diagnoses including stroke. A 1/4/23 Social Service Quarterly Review revealed the resident made her/his own decisions and was able to make her/his needs known using an interpreter. Resident 33's clinical record revealed no documentation to indicate the resident had an advance directive or was provided information concerning the right to formulate an advance directive. On 3/22/23 at 2:41 PM Staff 4 (Social Services Director) stated Resident 33 was her/his own responsible party and she did not provide the resident with an opportunity to formulate an advance directive.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0637 (Tag F0637)

Could have caused harm · This affected 1 resident

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Based on interview and record review it was determined the facility failed to document and conduct a Significant Change MDS assessment for 1 of 6 sampled resident (#38) reviewed for activities of daily living and hospitalizations. This placed residents at risk for unassessed care needs. Findings include: Resident 38 was readmitted to the facility 2/2023 after being hospitalized for longer than 24 hours. The resident's readmission diagnosis was fracture of the left femur. Resident 38's secondary diagnoses included dementia and diabetes. According to the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.15, 10/2017, a Significant Change is a major decline or improvement in a resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions; impacts more than one area of the resident's health status; and requires interdisciplinary review and/or revision of the care plan The nursing home may take up to 14 days to determine whether the criteria are met. After the IDT (interdisciplinary team) has determined that a resident meets the significant change guidelines, the nursing home should document the initial identification of a significant change in the resident's status in the clinical record. A Significant Change Status Assessment is appropriate when .the resident's condition is not expected to return to baseline within two weeks. Resident 38's 2/18/23 Discharge Return Anticipated MDS assessed the resident as being independent with transfers, dressing, personal hygiene and walking in room on and off the unit. This assessment also assessed the resident as needing supervision with bed mobility and toilet use. Resident 38's 2/25/23 Quarterly MDS assessed the resident as requiring extensive assistance with transfers, bed mobility, dressing, toilet use and personal hygiene. This assessment also revealed the resident did not walk in her/his room or off the unit. The resident walked on the unit only once or twice with the assistance of a staff member. Resident 38's 3/5/23 Care Plan indicated the following ADL care needs: - Extensive assistance with transfers with the use of a gait belt; - Extensive assistance with toileting with the use of a bedside commode; - Extensive assistance with bed mobility; - Extensive assistance with dressing; and - Extensive assistance with ambulation. There was no documentation in Resident 38's medical record which indicated a significant change assessment was considered or ruled out. On 3/23/23 at 9:52 AM Staff 5 (CNA) stated Resident 38 was independent with all her/his ADLs prior to fracturing her/his leg. Staff 5 stated after the resident experienced the fracture, she/he required a lot more assistance, especially with transfers and toileting, and the resident now ambulated with a wheelchair instead of walking with her/his walker. On 3/23/23 at 10:50 AM Staff 6 (LPN) acknowledged a significant change of condition should have been completed.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected 1 resident

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Based on interview and record review it was determined the facility failed to ensure a PASRR Level II (Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability) was completed for 1 of 1 sampled resident (#12) reviewed for PASRR. This placed residents at risk for not receiving specialized services. Findings include: Resident 12 was admitted to the facility in 2016 with diagnoses including anxiety, depression and cognitive-communication deficit. A 6/6/2019 PASRR Mental Health Evaluation was completed for Resident 12 which recommended a PASRR Level II be completed for an Intellectual Disability/Developmental Disability as the resident likely had a developmental disability. A review of the resident's medical record revealed a progress note dated 6/2/21 documenting the request for a PASRR Level II for Developmental Disability. No evidence was found in the resident's medical record that a PASRR Level II for Developmental Disability was completed. On 3/22/23/at 2:47 PM Staff 4 (Social Services Director) stated she was not aware Resident 12 needed a PASRR Level II related to Developmental Disability.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review it was determined the facility failed to ensure a resident's care plan accurately reflected their needs for 1 of 1 sampled resident (#8) reviewed for anticoagulant medication. Findings include: Resident 8 was admitted to the facility in 2023 with diagnoses including atrial fibrillation (irregular heart rhythm), bruising, anemia, coagulation deficit (lack of blood coagulation) and thrombosis (blood clots in large veins which may block blood flow or get lodged in the lungs). On 3/20/23 at 11:46 AM both of Resident 8's forearms were observed with numerous bruises. Her/his left forearm had a large healing scab. The resident stated she/he bruised from bumping into things and it did not matter how gentle it was. Resident 8's current physician's orders as of 3/2023 included aspirin once daily and Eliquis (anticoagulant) twice daily for atrial fibrillation. Resident 8's plan of care as of 3/2023 did not include monitoring for bruising or bleeding related to anticoagulant use. On 3/24/23 at 9:36 AM Staff 3 (LPN) confirmed Resident 8 received two anticoagulant medications (aspirin and Eliquis) which placed the resident at greater risk for bruising and bleeding. Staff 3 verified the resident's plan of care did not include monitoring for bruising or bleeding related to anticoagulant use.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0740 (Tag F0740)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to provide necessary behavioral health care and services for 1 of 1 sampled resident (#12) reviewed for behavioral-emotional needs. This placed residents at risk for unmet behavioral and emotional needs and a decrease in their quality of life. Findings include: Resident 12 was admitted to the facility in 12/2016 with diagnoses including anxiety and depression. A review of Resident 12's Patient Health Questionnaire (PHQ-9, a validated interview that screens for symptoms of depression) scores from 6/2018 to 9/2022 revealed the resident's scores ranged from zero to four, which was indicative of mild depression. Resident 12's [DATE] PHQ-9 score was 10, which indicated moderate depression. Resident 12's [DATE] Social Service Quarterly Review failed to identify the resident's increased PHQ-9 score on [DATE] or provide an assessment of the resident's mood state. Resident 12's [DATE] Care Plan indicated the resident had the potential for mood and behavior fluctuations and was receiving monthly mental health services. The Care Plan also included the following interventions related to mood and behavior: - Allow the resident to voice her/his needs and concerns and validate her/his feelings; - Provide opportunities for mental health services; and - PHQ-9 was to be completed quarterly and as needed. On [DATE] at 11:15 AM Resident 12 stated a counselor used to come and visit her/him but the visits had stopped and she/he did not know why. The resident stated these counseling visits were helpful and she/he wished they would resume. Resident 12 stated that since her/his family died, she/he preferred not to leave her/his bed and wanted to be by herself/himself. The resident indicated she/he wished the facility provided additional support with regards to coping with her/his losses and managing her/his emotions. On [DATE] at 2:47 PM Staff 4 (Social Services Director) stated she did not know why the resident's PHQ-9 score declined so significantly in 12/2022. Staff 4 stated she did not inform the resident's RNCM or medical provider of this change in scoring and she should have done so. Staff 4 further stated she was not aware Resident 12 received mental health services from an outside provider and she planned to remove this intervention from the resident's care plan as it was inaccurate. On [DATE] at 3:29 PM Staff 6 (LPN) reviewed Resident 12's PHQ-9 score from 12/2022 and stated she would have expected the Social Services Director to have reported this decline in the resident's self-reported mood. On [DATE] at 3:45 PM Staff 8 (Regional RN) provided documentation Resident 12 was last seen by her/his mental health provider on [DATE]. Staff 7 stated she was not sure why the counseling visits stopped. No attempts to communicate with the provider were made until [DATE] following an interview with the state surveyor.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

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Based on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 6 sampled residents (#22) reviewed for medications. This placed residents at risk for adverse medication consequences. Findings include: Resident 22 was re-admitted to the facility in 2022 with diagnoses including cancer and was receiving hospice services. Resident 22's 2/2023 MAR revealed the following narcotic medication orders: - Clonazepam (antianxiety) 1 mg, give one tablet every eight hours at 6:00 AM, 2:00 PM and 10:00 PM. The MAR indicated the clonazepam was administered at every ordered administration time from 2/1/23 through 2/26/23. - Lorazepam (antianxiety) 0.5 mg, give 0.5 mg every four hours at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM and 8:00 PM. The MAR indicated the lorazepam was administered at every ordered administration time from 2/18/23 through 2/26/23. Resident 22's controlled substance log book sheets revealed the following: - Page #27 indicated the clonazepam was administered on 2/20/23 at 12:00 AM and 4:00 AM. (The clonazepam was not ordered to be administered at 12:00 AM or 4:00 AM.) - Page #76 indicated the clonazepam was administered on 2/24/23 at 9:00 PM and 10:00 PM. (The clonazepam was not ordered to be administered at 9:00 PM.) - Page #56 indicated lorazepam doses were missed on 2/19/23 at 4:00 AM, 2/20/23 at 12:00 AM and 4:00 AM, 2/21/23 at 12:00 PM. On 2/20/23 at 9:24 AM the lorazepam dose was one hour and twenty four minutes late. On 3/24/23 at 9:10 AM Staff 2 (DNS) verified the clonazepam and lorazepam medication administration errors.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0801 (Tag F0801)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review it was determined the facility failed to employ a director of food and nutrition services with the required certification for 1 of 1 facility reviewed for qualified dietary staff. This placed residents at risk for unmet dietary needs. Findings include: Observations from 3/20/23 through 3/27/23 from 8:15 AM to 4:30 PM revealed Staff 7 (Food Service Manager) functioned in the capacity of the facility's director of food and nutrition services. On 3/20/23 at 3:42 PM Staff 7 reported he was currently enrolled in a program to become a Certified Food Service Manager and completed the required course. He stated he had not taken the exam yet but planned to in the next couple of weeks. He also stated he attended culinary school but was not sure if that would satisfy the requirements to be a director of food and nutrition services. A review of Staff 7's culinary certification revealed it did not meet the minimum requirements for a director of food and nutrition services. On 3/27/23 at 1:13 PM Staff 1 (Administrator) verified Staff 7 did not have the required qualifications to be a director of food and nutrition services.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review it was determined the facility failed to prepare and store foods in a manner to prevent cross contamination and spoilage for 1 of 1 kitchen reviewed for sanitary practices and 1 of 1 resident (#31) reviewed for food service and storage. This placed residents at risk of foodborne illness. Findings include: 1. On 3/20/23 at 9:10 AM during the initial tour of the facility's kitchen, the main prep island between the stove and dishwashing room was observed to have an open bag of chopped lettuce, an open container of sliced pickles, an open bin of sliced tomatoes and an open bin of sliced onions. Staff 8 (Dietary Aide) was observed scraping food debris from dishes into a garbage container. He reported the cook who was working with these items was on his break. No one else was observed working in the kitchen at that time. On 3/20/23 at 3:38 PM, Staff 7 (Food Service Manager) reported he was aware the cook left the items on the island to go to the bathroom. He reported he expected the items to be covered and stored in the refrigerator when they were not actively being used for meal preparation. 2. On 3/20/23 at 9:18 AM an observation was made of two glasses of milk covered with plastic tops dated 3/18 on Resident 31's overbed table. The milk was room temperature with what appeared to be small and large chunks of curdled milk floating in the top of both glasses. The facility's Outside Food and Safety Tips Policy indicated the following: -Discard any food left out at room temperature for more than two hours, or one hour if the temperature is above 90 degrees. On 3/20/23 at 3:21 PM Staff 12 (CNA) stated he did not like to leave resident trays in their rooms over 45 minutes with uneaten food or drinks. Staff 12 stated he would not leave milk or other dairy products out for extended periods of time due to how quickly they can go bad. On 3/20/23 at 3:57 PM Staff 2 (DNS) stated the facility would not typically allow milk to sit out for extended periods of time. Staff 2 stated it was her expectation CNAs should have taken the milk out of Resident 31's room in a timely manner. On 3/21/23 at 10:59 AM Staff 9 (LPN) stated she talked to Resident 31 regarding the glasses of milk. Staff 9 stated Resident 31 did not like to waste food and was planning on drinking the milk until she/he was shown the milk was curdled. Staff 9 stated the CNAs should have removed the glasses from Resident 31's room with the meal tray or soon after.

Nov 2022 6 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0554 (Tag F0554)

Could have caused harm · This affected 1 resident

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Based on interview and record review it was determined the facility failed to assess a resident's ability to safely self-administer medications for 1 of 1 sampled resident (#10) reviewed for self-administration of medications. Findings include: Resident 10 was admitted to the facility in 2022 with diagnoses including end stage renal disease, diabetes and bipolar disorder. The 11/22/22 admission MDS indicated the resident was cognitively intact. A review of Resident 10's clinical record revealed no medication self-administration assessment or physician orders the resident could self-administer her/his medications. An investigation dated 12/19/22 indicated on 12/19/22 Resident 10 received two doses of Oxycodone 10mg within 1 hour. The order for Oxycodone was to give 10mg by mouth every 4 hours as needed for pain. Resident 10 was noted to be drowsy and was to skip her/his next dose of Oxycodone until she/he was fully awake. The 12/2022 MAR revealed Oxycodone 10mg every 4 hours as needed for pain. On 12/19/22 at 5:05 AM Resident 10 was administered Oxycodone by Staff 5 (LPN). On 12/27/22 at 12:57 PM Staff 3 (RCM) stated Staff 5 (LPN) gave Resident 10 an extra dose of pain medication for her/him to take to her/his dialysis appointment. Staff 5 had not communicated with the dialysis nurses that Resident 10 was given her/his pain medication that morning. Staff 3 stated that Resident 10 was placed on alert charting and her/his physician had been notified. On 12/27/22 at 1:04 PM Staff 4 (CMA) stated Staff 5 (LPN) gave Resident 10 an extra dose of Oxycodone for her/him to take to dialysis. Staff 4 stated the incident was treated as a medication error. The resident was monitored for adverse side effects and education was provided. In an interview on 12/27/22 at 1:26 PM Staff 5 (LPN) explained she administered Oxycodone to Resident 10 on 12/19/22 at 5:05 AM for pain. Staff 5 stated Resident 10 was scheduled for dialysis that morning so she put a 10mg Oxycodone in an envelope, labeled it with the resident's name and the name of the medication, Staff 5 stated she did not send administration instructions for the Oxycodone with the resident. Staff 5 acknowledged she did not check to see if there was a physician order for the resident to self medicate or if the resident was assessed to take her/his own medications. On 12/27/22 at 2:00 PM Staff 2 (DNS) verified the 2 doses of Oxycodone were given to Resident 10 and the resident was not assessed to be able to self-administer their medications. In an interview on 12/27/22 at 2:35 PM Witness 1 (Dialysis Nurse) stated Resident 10 showed up to dialysis on 12/19/22 with a white envelope with her/his name on it and the name of the pain medication. The envelope was in a pouch on the side of Resident 10's wheelchair with no administration instructions. Resident 10 stated she was in pain at 6:00 AM and asked for some water to take the pain pill. Witness 1 stated if a resident came to dialysis with medication, they would take it at their own will. Witness 1 stated she recalled it was unusual for Resident 10 to show up to dialysis with medication.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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Based on interview and record review it was determined the facility failed to ensure a resident was free from neglect for 1 of 5 sampled residents (#8) reviewed for abuse and neglect. This placed residents at risk for neglect of care. Findings include: Resident 8 admitted to the facility in 2020 with diagnoses including osteoporosis. The 11/22/21 FRI indicated Resident 8 was left in a dirty brief for 70 minutes and requested Staff 13 (Former CNA) not take care of her/him anymore. An investigation was completed and Staff 13 was terminated. The 11/22/21 Incident Note indicated Resident 8 expressed she/he did not want Staff 13 and pleaded and cried when she/he requested to never have Staff 13 care for her/him again. The 11/22/22 Facility Investigation revealed revealed several residents who believed Staff 13 took a long time to answer call lights and requested Staff 13 not to care for them anymore. Staff Interviews revealed a strong pattern with Staff 13. Staff 13 would disappear, be found sleeping in the break-room and just stopped working or answering lights. The investigation found no physical harm occurred but Resident 8 was emotionally impacted and neglect of care was substantiated. On 11/7/22 at 11:10 AM Resident 8 stated Staff 13 left her/him in a dirty brief for 70 minutes and felt she/he was neglected by Staff 13. On 11/7/22 at 11:16 AM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Resident 8 was left in a dirty brief for 70 minutes, Resident 8 pleaded not to have Staff 13 work with her/him again and verified the facility investigation substantiated neglect of care.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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Based on interview and record review it was determined the facility failed to thoroughly investigate a potential medication error for 1 of 3 sampled residents (#10) reviewed for medications. This placed residents at risk for receiving another residents medications. Findings include: Resident 10 was admitted to the facilty in 2021 with diagnoses including hypertension. The 11/25/21 Incident Note revealed Resident 10 possibly received the incorrect medications on 11/14 PM [11/24/21 was date of incident]. Resident 10 remembered double checking with the nurse about the medications because she/he had never taken a magnesium tablet before, she/he did not take a red pill or a puffer. The nurse double checked the surrounding rooms' medications where it was noted the room next door had a magnesium, apixaban (blood thinner/pinkish colored pill) and an Advair inhaler (respiratory medication). The physician was notified of the possible medication error and ordered Resident 10 to be monitored for any change in level of consciousness or bleeding. [Resident 10 was prescribed Lovenox (blood thinner).] The 11/24/21 Facility Investigation revealed Resident 10 asked the nurse if she was sure she had the correct medications, the nurse told Resident 10 she already double checked in the computer so Resident 10 took the medications because the nurse told her/him they were hers/his and Resident 10 believed she/he should trust the nurse. The investigation did not include a statement from the nurse if she did or did not administer the medications and did not include reviewing the other residents medications to verify if the other resident medications had the correct number of doses left for the medications in question. The investigation did not determine if Resident 10 was administered another residents medications or not. On 11/2/22 at 11:55 AM Staff 1 (Administrator) and Staff 2 (DNS) verified the facility investigation was not thorough as it did not conclude if a medication error occurred and did not review the other residents medications for missing medications.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Assessments (Tag F0636)

Could have caused harm · This affected 1 resident

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Based on interview and record review it was determined the facility failed to assess a residents cognitive status for 1 of 3 sampled residents (#9) reviewed for ADLs. This placed residents at risk of incomplete cognitive assessments. Findings include: Resident 9 admitted to the facility in 2021 with diagnoses including diabetes. The RAI Manual, Section C revealed the items in this section were intended to determine the resident's attention, orientation and ability to register and recall new information. These items were crucial factors in many care planning decisions. The manual instructed a structured interview for the Brief Interview for Mental Status (BIMs) be attempted. If the BIMS was not attempted a Staff Assessment of Mental Status was to be completed. The 11/30/21 admission MDS, Section C revealed the BIMs interview and the Staff Assessment of Mental status were coded as not assessed. There was not evidence in the medical record why the BIMs or the Staff Assessment of Mental Status were not completed as required by the RAI Manual. On 11/8/22 at 9:43 AM Staff 1 (Administrator) verified the 11/30/21 admission MDS, Section C was not assessed and further stated, It certainly should have been done.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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Based on interview and record review it was determined the facility failed to ensure pressure ulcer assessments were completed accurately and treatment was implemented timely for 1 of 3 sampled residents (#5) reviewed for skin conditions. This placed residents at risk for worsening pressure injury and infection. Findings include: The facility's 9/2020 Skin at Risk/Skin Breakdown Policy indicated: -Full body skin evaluations were to be completed weekly and completion is documented. No indicated no new skin impairment and yes indicated new skin impairment. -Upon discovery of newly identified skin impairment (abrasion, skin tear, etc.) the licensed nurse would: *Document skin impairment that includes measurements of size, color, presence of odor and exudates. The National Pressure Injury Advisory Panel utilizes the follow pressure ulcer staging guidelines: * Stage 2: Partial-thickness skin loss with exposed dermis. * Stage 3: Full-thickness skin loss. Adipose (fat) tissue is visible, slough (yellow/white material/dead cells that accumulate in wound bed) and/or eschar (dead tissue) may be visable. * Stage 4: Obscurred full-thickness skin and tissue loss in which the extent of the tissue damage within the ulcer cannot be confirmed because it is obscurred by slough or eschar. If slought or eschar is removed, a Stage 3 or 4 pressure injury wil be reviewed. Resident 5 admitted to the facility in 2015 with diagnoses including multiple sclerosis (a disease affecting the central nervous system) and bilateral leg fractures. The 8/25/22 Significant Change MDS indicated Resident 5 did not have any skin breakdown but was at risk for developing pressure ulcers. A review of Resident 5's medical record starting 8/2022 revealed no evidence of weekly skin checks prior to 9/3/22. Resident 5's 9/3/22 Equipment Assessment indicated the resident was required to wear a tightly fit brace to her/his right leg related to a fracture. An exam of the skin under the brace showed a red area under the strap just below the inner knee. A hydrocolloid (moisture-retentive dressing) was applied, and a pad was placed between the brace and the resident's knee. There were no measurements or other descriptions of the wound. Resident 5's Skin Wound Evaluations were reviewed from 9/2022 through 10/2022 indicated the following: - 9/8/22: Right inner knee abrasion measuring 2.3 cm x 2 cm x 0 cm. the wound was noted to have 100% granulation. It was noted the wound was on the inner knee where the brace fit against the skin and appeared to be friction caused. This was noted to be the first evaluation of the wound and the wound was not present on admission. -9/15/22: Right inner knee Stage 2 pressure ulcer measuring 2.6 cm x 2.5 cm x 0 cm. The wound was noted to have 75% slough and 25% granulation with serous drainage. It was noted the resident saw an outside wound provider today to obtain measurements and photos. [The description described a Stage 3 or unstageable pressure ulcer.] -9/22/22: Right inner knee Stage 2 pressure ulcer measuring 2.6 cm x 2.5 cm x 0 cm. The wound was noted to have 75% slough and 25% granulation with serous drainage. It was noted the resident saw an outside wound provider today to obtain measurements and photos. The 9/22/22 evaluation had the same wording and measurements as the 9/15/22 evaluation. [The description described a Stage 3 or unstageable pressure ulcer.] -9/29/22: Right inner knee Unstageable pressure ulcer measuring 8.5 cm x 3.5 cm x 0 cm. The wound was beefy red with 25% slough, 50% granulation, and 10% epithelization. The wound was noted as improved. -10/6/22: Right inner knee Unstageable pressure ulcer measuring 1.1X1.2/ x 3.5 cm x 0 cm. The wound was beefy red with 100% granulation and moderate serosanguineous (watery fluid containing blood) drainage. [Does not meet definition to be staged as unstageable.] A 9/22/22 outside would provider note indicated Resident 5 had an Unstageable right medial lower leg pressure wound measuring 8.5 cm x 3.5 cm x 0 cm. The note indicated 9/22/22 was the initial assessment of Resident 5's right medial lower leg pressure ulcer. The pressure ulcer had 0-10% epithelialization, 26-50% granulation, 11-25% slough, and no eschar. Treatment orders included: 1. clean wound with wound cleanser. 2. apply skin prep to peri-wound and allow to dry. 3. apply xeroform (wound dressing) to base of wound. 4. cover with bordered foam. Place additional ABDS (cushion dressing) if necessary for extra padding. 5. change three times per week and prn for accidental removal, saturation and/or soiling. The 9/2022 TAR indicated the 9/22/22 identified treatment order from the outside wound provider was not implemented until 9/29/22. A 10/27/22 outside wound provider note indicated Resident 5's right medial lower leg pressure ulcer had resolved. On 11/7/22 at 11:51 AM Staff 3 (LPN Resident Care Manager) stated the weekly skin assessments were expected to be completed by staff but were not documented in Resident 5's medical record. Staff 3 stated Resident 5's right medial lower leg wound was a pressure ulcer due to a medical device and was unstageable as of 9/8/22. Staff 3 acknowledged the inconsistencies in the wound assessments for 9/8/22 and 9/15/22 and confirmed the 9/22/22 had the same wording as the 9/15/22 assessment. Staff 3 acknowledged the 9/22/22 facility skin evaluation was inconsistent and inaccurate compared with the outside wound provider's 9/22/22 wound assessment. Staff 3 confirmed the outside wound provider's first assessment of Resident 5's pressure ulcer was 9/22/22 and acknowledged the pressure ulcer treatment delay for the identified dates.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

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Based on interview and record review it was determined the facilty failed to ensure residents were free from significant medication errors for 1 of 3 sampled residents (#7) reviewed for medications. This placed residents at risk for receiving another residents medications. Findings include: Resident 7 admitted to the facility in 2021 with diagnoses including diabetes. A 7/12/22 Progress Note revealed Resident 7 was administered another residents medications which included oxycodone (narcotic pain medication), Seroquel (antipsychotic medication), melatonin (supplement), Senna (bowel medication), multiple Parkinson's medications and gabapentin (nerve pain medication). The physician was notified and instructed the facility to transfer the resident to the hospital for monitoring due to Resident 7's low tolerance for that many high-power medications and the risk for respiratory depression and adverse drug reactions. A 7/13/22 Progress Note revealed Resident 7 returned to the facility in the afternoon. A 7/14/22 Physician Note revealed the blood tests were completed in the hospital were essentially unremarkable and the resident was stable since her/his return to the facility. On 11/7/22 at 12:05 PM Staff 2 (DNS) verified Resident 7 received another residents medications, was transferred to the hospital for overnight monitoring and acknowledged this was a significant medication error.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"Why is there high staff turnover? How do you retain staff?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
• No fines on record. Clean compliance history, better than most Oregon facilities.

Concerns

• 37 deficiencies on record. Higher than average. Multiple issues found across inspections.
• 62% turnover. Above average. Higher turnover means staff may not know residents' routines.

Bottom line: Mixed indicators with Trust Score of 65/100. Visit in person and ask pointed questions.

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About This Facility

What is Stanley Post Acute's CMS Rating?

CMS assigns STANLEY POST ACUTE an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Oregon, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.

How is Stanley Post Acute Staffed?

CMS rates STANLEY POST ACUTE's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 62%, which is 16 percentage points above the Oregon average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 80%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Stanley Post Acute?

State health inspectors documented 37 deficiencies at STANLEY POST ACUTE during 2022 to 2025. These included: 37 with potential for harm.

Who Owns and Operates Stanley Post Acute?

STANLEY POST ACUTE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by PACS GROUP, a chain that manages multiple nursing homes. With 96 certified beds and approximately 84 residents (about 88% occupancy), it is a smaller facility located in MILWAUKIE, Oregon.

How Does Stanley Post Acute Compare to Other Oregon Nursing Homes?

Compared to the 100 nursing homes in Oregon, STANLEY POST ACUTE's overall rating (4 stars) is above the state average of 3.0, staff turnover (62%) is significantly higher than the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.

What Should Families Ask When Visiting Stanley Post Acute?

Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's high staff turnover rate.

Is Stanley Post Acute Safe?

Based on CMS inspection data, STANLEY POST ACUTE has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in Oregon. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Stanley Post Acute Stick Around?

Staff turnover at STANLEY POST ACUTE is high. At 62%, the facility is 16 percentage points above the Oregon average of 46%. Registered Nurse turnover is particularly concerning at 80%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?

Was Stanley Post Acute Ever Fined?

STANLEY POST ACUTE has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Stanley Post Acute on Any Federal Watch List?

STANLEY POST ACUTE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 96
Avg. Residents: 84
Occupancy: 87.5%
Ownership: For profit - Limited Liability company
Chain: PACS GROUP
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
4-Star Rating: +30
High Turnover: -5
37 Deficiencies: -10
Final Score: 65/100

Nearby Alternatives

WILLAMETTE VIEW HEALTH CENTER 5-star MARQUIS HOPE VILLAGE 5-star MARQUIS WILSONVILLE POST ACUTE... 5-star

View all in MILWAUKIE →

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 385270