Menlo Park Post Acute: Missed Eye Medication - OR
The resident, identified in inspection records only as Resident 6, was admitted to the facility with a serious list of conditions: end stage renal disease, dependence on renal dialysis, conjunctivitis, and a perforated corneal ulcer in her right eye. Her care plan, initiated February 12, 2026, flagged her as being at risk for complications from a bilateral eye infection. That same day, her physician ordered erythromycin ophthalmic ointment applied to her left eye five times a day.
The medication records tell a precise story of what happened next. On February 16, a certified medication aide documented that the 11:00 AM dose was not given because the resident was at dialysis. The same entry appeared on February 17. And February 18. On February 23, the 11:00 AM dose was skipped again for the same reason. That afternoon, a second medication aide noted the resident was "absent from home." The same aide logged two more missed doses on February 25, and another on February 27.
Eight missed doses. Twelve days. No call to the nurse. No call to the doctor.
When inspectors interviewed the first medication aide on May 21, she confirmed her practice: if a resident was out of the facility for dialysis when a medication was due, she would note it on the record and move on. She did not communicate with the nurse about the missed antibiotic eye medication. The second aide said she could not recall whether she had notified anyone, and was unsure whether the physician even knew doses had been skipped.
The charge nurse on duty during those February shifts told inspectors she was never informed. "Staff 18 and Staff 19 did not communicate with her on 2/16/26, 2/23/26 or 2/27/26 that Resident 6 had missed her/his antibiotic eye medication due to being out of the facility for dialysis," according to the inspection report. She said the medication aides should have told her so she could contact the provider.
The facility's registered nurse care manager said the same thing. So did the director of nursing services, who described exactly what should have happened: the aides notify the charge nurse, the charge nurse coordinates with the care manager and the provider, and the medication schedule gets adjusted to account for the resident's dialysis appointments.
None of that happened.
The gap between what the facility's own leadership described as standard practice and what the medication records show is the core of what inspectors cited. Dialysis is not an unexpected absence. Resident 6's need for renal dialysis was documented in her admission records, her comprehensive assessment, and her care plan. Her dialysis schedule was not a surprise on February 16, or the 17th, or the 18th. The missed doses were logged and filed, and the information stopped there.
Inspectors spoke directly with Resident 6 on May 19, nearly three months after the missed doses. She told them she was not receiving her eyedrops as ordered.
The inspection, conducted as a complaint investigation, was completed May 22, 2026. Inspectors cited the facility for failing to follow physician orders, noting the deficiency placed residents at risk for unmet care needs. The harm level was classified as minimal harm or potential for actual harm.
There is no documentation in the inspection record that Resident 6's physician was ever told she had missed eight doses of antibiotic eye medication while being treated for a perforated corneal ulcer and a bacterial infection. The resident knew. She told inspectors herself.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Menlo Park Post Acute from 2026-05-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
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Last verified: October 31, 2026 · Our methodology
MENLO PARK POST ACUTE in PORTLAND, OR was cited for violations during a health inspection on May 22, 2026.
Her care plan, initiated February 12, 2026, flagged her as being at risk for complications from a bilateral eye infection.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.