The Stayton at Museum Way

Inspectors wroteBased on interview and record review the facility failed to implement an admissions policy that did not request or require residents to waive potential facility liability for loss of personal property for 2 of 2 residents (Resident's #1 and #2) reviewed for loss of personal property. The facility failed to ensure the admission agreement did not request or require residents to waive potential facility liability for losses of personal property. This could place residents at risk of misappropriation of their personal property.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispending, and administering of all drugs and biologicals, to meet the needs of each resident for 1 medication cart (Hall B cart) and 1 medication room (Hall A) reviewed for pharmacy services. The facility failed to ensure expired multivitamin with zinc, with a date of 08/2025 in the Hall B nurse cart, and 2 bottles of expired multivitamin with an expiration date of 05/2025, 1 bottle of multivitamin with an expiration date of 08/2025, 3 bottles of niacin with an expiration date of 09/2025, and a box of bisacodyl suppositories with an expiration date of 06/2025 in the Hall A medication room were removed and destroyed. This failure could place residents at risk of receiving expired medications that were ineffective.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure any drug regimen irregularities reported by the Pharmacist Consultant were acted upon, for 1 of 5 residents (Resident #5) whose drug regimens were reviewed. The facility failed to act upon the Pharmacy Consultant's recommendations issued on 07/21/25, 08/19/25, and 09/22/25 to add a 14-day stop date for Resident #5's use of PRN Lorazepam, which is a psychotropic medication used for the treatment of anxiety disorders and severe agitation. This failure could place residents receiving medications at risk for adverse consequences and could cause a decline in their physical, mental, and psychosocial condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident was not given a psychotropic drug unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents (Resident #5) reviewed for unnecessary medications, in that: The facility failed to ensure Resident #5 was prescribed a psychotropic drug for anxiety no longer than 14 days PRN. Resident #5 was ordered PRN Lorazepam (a benzodiazepine medication used primarily to treat anxiety disorders and severe agitation) on 07/19/25 without a stop date. This failure could place residents at risk of receiving unnecessary psychotropic medications.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure residents had the right to be free from abuse and neglect for 2 (Residents #1 and #2) of 7 residents reviewed for abuse and neglect. 1. CNA A neglected Resident #1 safety and well-being when he placed a skeleton in the resident's doorway, which startled the resident and caused her to fall sustaining a skin tear and bruising on her buttocks. 2. The facility neglected to put measures in place to monitor Resident #2 after the resident injested medications, Fioricet (a barbituate used for headaches), that belonged to a family member. This resulted in the resident being unresponsive and going to the hopsital where she received IV fluids. The family member continued to visit four more times after this incident. These failures could result in residents receiving injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately to the state survey agency but no later than 2 hours after the allegation was made for 1 of 7 residents (Resident #2) reviewed for abuse and neglect. The facility failed to report an allegation of neglect when Resident #2 was found to have taken barbituates (Fioricet [used to treat headaches]) that belonged to a family member, which resulted in the resident being unresponsive and being sent to the hospital where she received IV fluids. This failure could place the resident at risk of continued abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure that each resident who was incontinent of bladder received appropriate treatment and services for 1 of 2 residents (Resident #1) reviewed for incontinence care. The facility they failed to monitor and document signs and symptoms of bowel movements for Resident#1. This failure could place residents at risk of not having their individual needs met, not receiving necessary care and services, and a decreased quality of life.

Inspectors wroteBased on observations and interviews, the facility failed to assure that medications were secure and inaccessible to unauthorized staff and residents, for 1 of 3 medication carts (medication cart #1) observed for medication storage. On 10/27/24 at 6:08 PM, RN A failed to ensure medications were secured or attended to by authorized staff when RN A did not lock medication cart #1. On 10/27/24 at 6:08 PM, RN A failed to ensure medications were secured or attended to by authorized staff when RN A left a medication cup with two pills and a resident's medication blister pack with pills on top of the medication cart unattended. These failures place residents at risk of a potential for more than minimal harm if a resident accessed and ingested medications or drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify and provide needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one (Resident #2) of five residents reviewed for wounds. 1. RN A failed to remove the semi-occulsive dressing (a type of wound dressing that allows air to pass through while protecting the wound from liquids) that secured the negative pressure wound therapy ([NPWT] - wound vac) suction device and tubing over the wound. RN A pulled on the suction device and tubing to remove the old dressing that caused Resident #2 pain and discomfort on 10/26/24. 2. RN A failed to follow the facility's general procedure for wound vac dressing change on 10/26/24. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, and administering medications for 1 of 3 residents (Resident #3) reviewed for medication administration. RN A failed to administer medications as ordered. RN A informed Resident #3 that he mixed Miralax (brand name of an over-the-counter powder that treats occasional constipation [generic name: Polyethylene glycol (PEG) 3350]) with cranberry juice per Resident #3's request to relieve constipation. Resident #3 did not have an order for Miralax (or generic version). The facility failed to ensure RN A contacted the physician to obtain an order for a medication before administration. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of infectious diseases and infections 1 of 5 residents (Resident #2) reviewed for infection control, in that: 1. RN A failed to follow facility protocol and don a gown in addition to gloves to reduce the risk of transmission of bloodborne pathogens and apply enhanced barrier precautions (EBP) when he performed wound vac dressing change to Resident #2's right knee on 10/26/24. 2. RN A re-used the wound vac disposable components (suction device and tubing) when he performed wound vac dressing change to Resident #2's right knee on 10/26/24. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for three (Resident #8, Resident #21, and Resident #143) of thirteen residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #8, Resident #21, and Resident #143's rooms were in a position that was accessible to the residents. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three (Resident #29, Resident #142, and Resident #144) of eight residents reviewed for Respiratory Care. 1. The facility failed to ensure that Resident #29's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was properly stored. 2. The facility failed to ensure that Resident #142 had an order for CPAP and her nasal pillow mask (a small, soft, cushioned inserts that rests at the entrance of the nose) for CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open) was stored properly. 3. [...]

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. 1. The facility failed to ensure expired foods in the facility's refrigerator and freezer were discarded according to guidelines. 2. The facility failed to ensure foods in the refrigerator and freezer were properly sealed from air-borne contaminations. 3. The Executive Chef, Cook, and Culinary Aide failed to properly wear a hair and beard covering while breakfast was being prepared and served, in the kitchen area. 4. The facility failed to clean the food storage bins in the dry food storage area. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure each resident was treated with respect and dignity and cared for in an environment that enhanced his or her quality of life for 2 (Resident #19 and #24) of 3 residents reviewed for dignity. The facility failed to treat Resident #19 and #24 with dignity and enhance their quality of life when the residents were not provided a privacy bag for their catheter bag (drainage bag outside of the body that collects urine). This failure placed residents at risk of not having their right to dignity maintained.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that assessments accurately reflected the resident's status for one (Resident #142) of seven residents reviewed for Accuracy of Assessments. The facility failed to ensure Resident #142's Comprehensive MDS Assessment accurately reflected that Resident #142 was using a CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open). This failure could place residents at risk for not receiving care and services to meet their needs, for diminished function of health, and for regressions in their overall health.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for one (Resident #142) of seven residents reviewed for Care Plans. The facility failed to ensure Resident #142 was care planned for CPAP. This failure could place the residents at risk of not receiving the necessary care and services.

Inspectors wroteBased on interviews, and record reviews, the facility failed to review and revise the comprehensive person-centered care plan for each resident, consistent with the resident right that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #23) of 6 residents reviewed for Care Plan reassessment and revisions. The facility failed to ensure Resident #23's care plan included the resident receiving a dietary supplement (Ensure), twice daily based on a comprehensive nutritional assessment completed by the dietician on 08/16/24. This failure could place the resident at risk for excessive weight loss.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure that residents received additional nutrition resources, based on comprehensive assessments reviewed for 1 (Resident #23) of 4 residents reviewed for assisted nutrition. The facility failed to ensure Resident #23 received her Ensure shake twice daily, based on a dietary comprehensive assessment completed by the Dietitian on 08/16/24. This failure placed the resident at risk of unnecessary weight loss or slowing a diagnosis that causes weight loss.

Inspectors wroteBased observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #7 and Resident #145) of eight residents observed for Infection Control. 1. The facility failed to ensure that CNA C changed her gloves and performed hand hygiene while providing incontinent care to Resident #7. 2. The facility failed to ensure that CNA B changed her gloves and performed hand hygiene while providing incontinent care to Resident #145. These failures could place the residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program with a system for preventing, identifying, and controlling infections and communicable diseases for all residents, staff, visitors, and other individuals providing services based upon national standards for 1 (A-Tower) of 2 halls reviewed for infection control. The facility failed to have an effective protocol in place to prevent the spread of COVID-19 that followed nationally accepted standards for contact tracing testing or broad-based testing after CNA A tested positive for COVID-19 on 12/29/23. The facility had not implemented testing on days 1, 3, or 5 to identify others who may have been exposed. These failures could place residents and staff at risk for cross-contamination and the spread of infection.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 of 2 residents (Resident #4 and Resident #23) reviewed for respiratory care. The facility failed to ensure Resident #4's (two tubings) and Resident #23's (one tubing) nasal cannula tubing were dated. This failure could place residents at risk of not having their respiratory needs met.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. The facility failed to ensure foods in the facility's dry storage area, refrigerator, and freezer were stored and dated according to guidelines. The facility failed to ensure that staff was wearing the proper head and face coverings when serving food. The facility failed to ensure proper discarding of expired food stored in the refrigerator and freezer storage area. These failures could place residents at risk for cross contamination and other air-borne illnesses.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that 1 (Resident #188) of 1 resident who is fed by enteral means, received the appropriate treatment and services to prevent complications of enteral feeding for 1 (Resident #188) of 3 residents reviewed for enteral feeding. The Facility failed to ensure Resident #188's feeding bag was dated as per facility' policy. This failure could place the residents at risk for nutritional problems.

Inspectors wroteBased observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #4) of 3 residents observed for infection control. The facility failed to ensure that the two prongs of Resident #4's nasal cannula (a device used to deliver supplemental oxygen to an individual. It consists of a lightweight tube on which one is connected to the oxygen source and the other end splits into two prongs and are placed in the nostrils) was off the floor and not touching any surface when not in use. This failure could place the residents at risk of cross-contamination and infections.