Average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avalon Care Center - Portland during CMS and state inspections, most recent first.
The facility failed to provide written transfer notices and written bed-hold policy information to three residents or their representatives at the time of hospital transfer. One resident with UTIs and sepsis and another with chronic heart failure, both responsible for their own decisions, were transferred without documented written notice or bed-hold information. A third resident with peripheral vascular disease, whose daughter was the responsible party, was transferred twice without documentation that the representative was notified. An LPN reported not documenting which documents were sent and that no written transfer notices were available, another LPN was unaware of the requirement to provide bed-hold or transfer notices, and the DNS could not find any related documentation and was unaware written transfer notices were required, while the administrator acknowledged such notices and bed-hold information were supposed to be provided.
A resident with Parkinson’s disease and anxiety, who was cognitively intact and care planned to be involved in daily decisions, repeatedly told staff and administration that they did not want a specific CNA providing their care. Despite the facility’s policy supporting resident self-determination and choice of health care providers, staffing records and observations showed that this CNA continued to be regularly assigned to the resident and provided care over multiple days. Several staff, including CNAs, social services, the staffing coordinator/HR, and the DNS, acknowledged awareness of the resident’s ongoing complaints and preference, but assignments were not changed, with leadership citing staffing challenges.
A resident with peripheral vascular disease was transferred to the hospital on multiple occasions, but the responsible party listed as the emergency contact was not notified, contrary to the facility’s Notification of Changes of Condition Policy. Nursing staff reported that their usual practice was to notify the emergency contact or responsible party before or immediately after a transfer and to document this in the clinical record, yet no such documentation existed for these transfers. Facility leadership later confirmed that the resident’s representative had not been notified and that nursing staff were not consistently contacting resident representatives regarding hospital transfers.
A resident with severe cognitive impairment, a history of sexual assault trauma, and a care plan noting preference for female staff was sexually abused by another cognitively impaired resident who had alcohol-induced persisting dementia, high-risk heterosexual behavior, and a documented history of sexual behaviors toward female residents. The second resident’s care plan required supervision around female residents, redirection of sexual behaviors, and intermittent 1:1 supervision after incidents, yet clinical records showed multiple prior sexually inappropriate incidents without evidence that 1:1 supervision was implemented. Staff reported that this resident was not to be alone with female residents, but the staffing coordinator observed the resident in a common area with a hand under the other resident’s shirt, fondling the breast while the victim tried to push the hands away, with no other staff present.
A resident with a history of cerebral infarction and depression was not properly assessed for the use of a power wheelchair, despite documented goals and improvements in fine motor and visual skills. Therapy sessions focused on related skills, but no direct evaluation with the power wheelchair occurred, and the resident's request for increased independence and socialization was not addressed through appropriate assessment.
Two residents with mental health diagnoses did not receive the required PASARR screenings. One resident with schizophrenia and anxiety did not have a PASARR II completed despite indications it was needed, and another resident with bipolar disorder and PTSD did not have a PASARR I screening on record. Staff confirmed these omissions during the survey.
A resident with dementia and PTSD, who had severe cognitive impairment, was not provided with activities aligned to their documented preferences, such as pet visits, listening to preferred music, group participation, or outdoor time. Despite staff and family confirming these interests, the care plan lacked these details, and the resident was observed sitting alone without engagement or inclusion in ongoing activities.
A resident with a right leg amputation who required two-person mechanical lift transfers was assisted by only one CNA without the lift, resulting in a fall. The CNA relied on the resident's statement about their transfer needs, but the care plan still required a mechanical lift and two-person assistance, which was not followed.
A resident with a history of UTIs was prescribed Bactrim for prophylaxis and later received cefuroxime, resulting in duplicate antibiotic therapy without documented review or rationale. Staff recognized the issue and attempted to clarify with the PCP, but no response was received and no justification for the dual therapy was documented, contrary to the facility's antibiotic stewardship policy.
A resident sustained second-degree burns due to the facility's failure to enforce its smoking policy. The policy required staff management of smoking materials, but residents were allowed to possess and use them independently. This led to an incident where a resident was injured while refilling another resident's lighter. Staff and residents confirmed the lack of policy enforcement, and the administrator acknowledged the safety failure.
The facility failed to protect residents from physical and sexual abuse, resulting in one resident sustaining injuries from an altercation with another resident and another resident being inappropriately touched by a fellow resident. Staff were aware of the behavioral issues but did not adequately monitor or intervene to prevent these incidents.
The facility failed to store and handle food in a sanitary manner in one of its kitchens. Observations included uncovered, unlabeled, and undated food items in the refrigerator and freezer, as well as spilled prune juice. The administrator confirmed these issues.
The facility failed to accommodate a resident's lighting needs, leaving them unable to reach the overbed light switch due to a short cord. Despite reporting the issue, it remained unresolved. The Maintenance Director and Administrator acknowledged the problem and the need for repair.
The facility failed to obtain copies of advance directives and inform two residents of their right to formulate advance directives. One resident had a care plan indicating an advance directive, but no documentation was found in their health record. Another resident had no documentation or discussion about advance directives despite being their own responsible party.
A resident with severe cognitive decline and chronic conditions was sent out of the facility for an appointment without notifying her/his representative, as required by the admission agreement. The Administrator acknowledged this lapse in notification.
A resident with a non-pressure chronic ulcer and type 2 diabetes, who was moderately cognitively impaired, was found to have a gouge in the wall adjacent to their bed. The Maintenance Director acknowledged the issue and stated it should have been fixed before the resident moved in. The Administrator also deemed the condition unacceptable.
The facility failed to provide a written summary of a baseline care plan within 48 hours of admission for two residents. Both residents, admitted with serious health conditions, did not receive their baseline care plans, and staff members were unaware of the requirement to provide and review these plans.
The facility failed to develop a person-centered comprehensive care plan for a resident diagnosed with PTSD. Although the resident's admission MDS noted the PTSD diagnosis and indicated the need for interventions, the comprehensive care plan lacked focus, goals, or interventions for PTSD symptoms. The Social Services Director confirmed the oversight.
The facility failed to follow physician orders for a resident with lymphedema and erythema. The resident's ACE wraps were not applied on multiple dates in May, and the resident was observed wearing ragged wraps that had not been removed for a week. Staff confirmed the non-compliance with the physician's orders.
The facility failed to provide adequate care and hazard removal for two residents. One resident, with obesity and dementia, fell out of bed when only one staff member was present during care, despite a care plan requiring two. Another resident, with severe cognitive impairment, was found with electric burners in their room, which staff were unaware of until they were removed by the Administrator.
The facility failed to maintain oxygen equipment and ensure oxygen was administered as ordered for two residents. One resident with COPD had a dusty oxygen concentrator filter, and another resident with congestive heart failure received an incorrect oxygen flow rate. Staff acknowledged these issues, and the DNS confirmed the expectations for equipment maintenance and oxygen level checks.
The facility failed to accurately document wound care for a resident with lymphedema and erythema. Despite physician's orders to apply and remove ACE wraps daily, records showed inconsistencies, and the resident reported wearing the same wraps for a week without removal. An observation confirmed the wraps were ragged and nearly falling off, and staff acknowledged the documentation inaccuracies.
Failure to Provide Written Transfer Notices and Bed-Hold Policy at Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to provide written notice of transfer and written information on the facility’s bed-hold policy at the time of hospital transfer for three residents. The facility’s 7/2018 Notification of Changes of Condition Policy directs staff to promptly notify the resident representative when there is a decision to transfer a resident to the hospital. For one resident admitted in 6/2024 with diagnoses including urinary tract infections and sepsis, the admission profile indicated the resident was responsible for themselves, and the clinical record showed a hospital transfer on 2/12/26 with no evidence that written notice of transfer or the facility’s bed-hold policy was provided. Another resident, admitted in 2/2025 with peripheral vascular disease and whose admission profile identified their daughter as the responsible party, was transferred to the hospital on two occasions, with no documentation that the representative was notified of either transfer. A third resident, admitted in 4/2025 with chronic heart failure and responsible for their own decisions, was transferred to the hospital on 2/12/26 without any documented evidence that written notice of transfer or the facility’s bed-hold policy was provided. During interviews, one LPN stated she did not document which documents were sent with residents transferring to the hospital and confirmed the facility did not have written transfer notices to provide to residents or representatives. Another LPN reported being unaware of the requirement to provide a bed-hold policy or transfer notice when residents were transferred. The DNS was unable to locate any documentation confirming that the bed-hold policy or written transfer notifications were provided to the three residents or their representatives, and stated she was unaware that written transfer notification was required, while the Administrator acknowledged that written transfer notification and the bed-hold policy were supposed to be provided at the time of transfer.
Failure to Honor Resident Choice of CNA Caregiver
Penalty
Summary
Surveyors identified a failure by the facility to honor a resident’s right to self-determination and choice of health care providers. The facility’s Resident Rights: Right to Self-Determination Policy, dated 7/2018, stated that residents have the right to choose health care and providers of health care services and that the facility would promote and facilitate resident self-determination and autonomy. Resident 1, admitted with Parkinson’s disease and anxiety, had a trauma care plan revised on 5/30/25 instructing staff to involve the resident in cares and daily decisions, and Minimum Data Set (MDS) assessments indicated no cognitive impairment. Despite this, Resident 1 repeatedly told several staff members and administration that they did not want Staff 3, a CNA, in their room or providing care. The resident reported that they had tried multiple times to have Staff 3 not work with them, but Staff 3 continued to be assigned and was their CNA on the day of observation. Record review of staff assignment sheets from 3/24/26 through 4/6/26 showed that Staff 3 was assigned to care for Resident 1 on multiple days within that period, and surveyor observations confirmed Staff 3 provided care and services to the resident during the day shift. Staff 3 acknowledged that the resident did not like them as their CNA and that nursing staff and upper management were aware, yet they continued to be assigned to the resident. Another CNA confirmed that Resident 1 did not want Staff 3 assisting them. Social services staff stated the resident had reported not wanting Staff 3 as their CNA several times and that this concern had been discussed among staff for a while, with the information passed to the Administrator and DNS. The staffing coordinator/human resources staff confirmed the resident’s complaints and stated that CNA assignment changes were made if a teammate requested a change, and that leadership was aware of the resident’s request. The DNS acknowledged awareness of the resident’s wishes, confirmed the repeated assignments of Staff 3 to the resident, and stated that although it was the resident’s right to choose who cared for them, there were staffing challenges and many considerations in CNA assignments.
Failure to Notify Resident Representative of Hospital Transfers
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of hospital transfers as required by its Notification of Changes of Condition Policy. The policy, dated 7/2018, directed staff to promptly notify the resident representative when there was a decision to transfer a resident from the facility to the hospital. Resident 4, admitted in 2/2025 with diagnoses including peripheral vascular disease, had an admission profile listing Witness 4 as the responsible party and emergency contact. Record review showed that the resident was transferred to the hospital on two occasions, including 12/18/25, with no documentation in the clinical record that the resident’s representative was notified of these transfers. During interviews, nursing staff confirmed that the practice was to notify the emergency contact or responsible party listed on the face sheet before or immediately after a resident left the facility and to document this in the clinical record. Specifically, two LPNs stated that family or the listed emergency contact were to be contacted when residents transferred to the hospital and that they documented who was contacted. However, on 4/7/26, the DNS and the Administrator confirmed that Witness 4 was not notified when the resident was transferred to the hospital on 12/18/25 and acknowledged that nursing staff were not contacting resident representatives as required, leading to the identified deficiency.
Failure to Prevent Sexual Abuse by Resident With Known History of Sexual Behaviors
Penalty
Summary
The facility failed to protect a resident from sexual abuse when a cognitively impaired resident with a known history of sexually inappropriate behavior was allowed to be alone with another cognitively impaired resident. Facility policy defined sexual abuse as non-consensual sexual contact of any type with a resident who lacked the cognitive ability to consent or did not want the contact. One resident had relapsing multiple sclerosis, mild cognitive impairment, and was assessed on a quarterly MDS as having severe cognitive impairment. This resident’s care plan documented past sexual assault trauma, a preference for female staff, and impaired cognition. Another resident, admitted with alcohol-induced persisting dementia and high-risk heterosexual behavior, was assessed as having moderate cognitive impairment. That resident’s care plan identified a history of sexual behaviors toward female residents and directed staff to ensure supervision when around female residents, to redirect sexual behaviors, and to place the resident on intermittent 1:1 supervision after incidents for the safety of others. Clinical record review for the resident with sexually inappropriate behaviors showed multiple prior incidents, including an attempt to touch a female resident, being found in female residents’ rooms, sexually touching female staff, and increased sexual behaviors, with no evidence that 1:1 supervision was implemented after these events as care planned. Multiple CNAs reported that this resident was not supposed to be alone with female residents and that staff were expected to redirect the resident from entering rooms or demonstrating sexual behaviors when not on 1:1 supervision. Despite this, the staffing coordinator/human resources staff member observed the resident in the dining room with a hand under the other resident’s shirt, fondling the resident’s breast, while the victim attempted to push the hands away, and no other staff were present in the area. The administrator and DNS confirmed that the resident had a known history of sexual behaviors toward others and acknowledged that this incident constituted abuse.
Failure to Assess Resident's Ability to Use Power Wheelchair
Penalty
Summary
The facility failed to ensure a resident's right to a dignified existence and self-determination regarding the use of a power mobility device. A resident with a history of cerebral infarction and depression was admitted and had a goal, as documented in an occupational therapy evaluation, to operate a power wheelchair with standby assist to maximize socialization. Despite this, therapy records showed that while the resident received services aimed at improving skills related to power wheelchair use, no actual assessment involving the use of the power wheelchair was performed. Scheduled power wheelchair training sessions did not occur, and the decision to discontinue the use of the device was based on perceived deficiencies in tactile feedback and visual scanning, without direct assessment of the resident's abilities in the power wheelchair. Interviews and observations revealed that the resident expressed a desire to use the power wheelchair to increase independence and socialization, and staff noted improvements in the resident's functional use of hands and ability to perform self-care tasks. The resident was observed participating independently in activities requiring fine motor and visual scanning skills, and staff confirmed improvements in these areas. Despite these observations and the resident's normal cognitive function, the facility did not conduct a direct assessment of the resident's ability to safely use the power wheelchair, as confirmed by the Director of Nursing Services.
Failure to Complete Required PASARR Screenings for Residents with Mental Disorders
Penalty
Summary
The facility failed to ensure appropriate completion of PASARR (Preadmission Screening and Resident Review) screenings for two of three sampled residents with mental disorders or intellectual disabilities. One resident, admitted with diagnoses of schizophrenia and anxiety, had a PASARR I assessment indicating the need for a PASARR II due to the schizophrenia diagnosis, but no PASARR II was found in the electronic health record. Staff confirmed that the required PASARR II had not been completed. Another resident, admitted with bipolar disorder and PTSD, did not have a PASARR I screening available in the record at the time of the survey. Staff interviews confirmed that the PASARR I was not completed for this resident upon admission, as required by facility policy.
Failure to Honor and Provide Resident Activity Preferences
Penalty
Summary
The facility failed to ensure that activities were honored and provided according to the preferences and needs of a resident with dementia and PTSD, who had a severe cognitive impairment as indicated by a BIMS score of six. The resident's admission MDS documented that it was very important for them to be around animals, do favorite activities, go outside in good weather, and listen to preferred music. However, the care plan only noted a general enjoyment of music and did not include specific preferences such as pet visits, listening to chosen music, group activities, or going outside. Observations over several days showed the resident sitting alone in common areas with little to no staff interaction and not being included in group activities occurring nearby. Interviews with the resident, their representative, CNAs, and the Activities Director confirmed that the resident enjoyed country and older rock music, liked dogs, and would participate in activities if invited. Staff were either unaware of the resident's preferences or had not included the resident in one-on-one visits or group activities. The Activities Director acknowledged that key preferences were missing from the care plan and were not being offered. The Administrator confirmed that the care plan did not reflect the resident's activity preferences and that activities were not being offered as expected.
Failure to Follow Care Plan for Safe Resident Transfer
Penalty
Summary
A deficiency occurred when the facility failed to implement care planned transfer interventions for a resident with a right leg amputation who required two-person assistance with a mechanical lift for transfers from bed to a shower chair. Despite the care plan in place, the resident was transferred by a single CNA without the use of a mechanical lift, contrary to the documented requirements. This resulted in the resident experiencing a fall during the transfer process. Interviews revealed that the CNA acted based on the resident's statement that they no longer needed the mechanical lift and only required assistance from one staff member, as the resident was working with therapy on slide board transfers. However, the care plan at the time of the incident still required a two-person mechanical lift transfer, and staff were expected to review and follow the care plan. The Director of Nursing Services acknowledged that the care plan was not followed in this instance.
Failure to Review and Document Rationale for Duplicate Antibiotic Therapy
Penalty
Summary
A deficiency occurred when a resident with a history of urinary tract infections (UTIs) was prescribed Bactrim for UTI prophylaxis and later received a second antibiotic, cefuroxime, without documented review or rationale for the concurrent use of both antibiotics. The resident was initially admitted with acute kidney failure, dysuria, and urinary retention, and was placed on Bactrim for ongoing UTI prevention. After reporting symptoms suggestive of a UTI, the resident was evaluated in the emergency department, where no infection was found. Subsequently, the resident's primary care provider prescribed cefuroxime following a urine dipstick that showed trace leukocytes, resulting in the resident receiving both antibiotics simultaneously. Facility staff, including nursing and infection control personnel, recognized the duplicate antibiotic therapy and attempted to contact the resident's primary care provider for clarification regarding the necessity of both medications. Despite these attempts, there was no response from the provider, and no documentation was made to justify the dual antibiotic regimen. The facility's antibiotic stewardship policy required validation of antibiotic use for correct indication, dose, route, and duration, but this was not followed in this case, as there was no documented rationale for the continued use of both antibiotics.
Failure to Enforce Smoking Policy Leads to Resident Injury
Penalty
Summary
The facility failed to implement and enforce its smoking policy, resulting in a resident sustaining a second-degree burn. The facility's smoking policy, dated January 20, 2023, required that smoking and smoking paraphernalia be managed and distributed by staff, with residents returning all smoking materials to a centralized storage box after use. However, the facility did not enforce this policy, allowing residents to possess and use smoking materials independently. This lack of enforcement led to an incident where a resident, admitted in February 2024 with chronic kidney disease, sustained burns while refilling another resident's butane lighter. The incident occurred on October 4, 2024, when the resident set their hand on fire while attempting to refill the lighter. The resident suffered burns to the middle, ring, and little fingers of their left hand. Interviews with the resident and another resident confirmed that the facility did not enforce the return of smoking materials, and staff acknowledged the facility's inability to manage the smoking policy. The facility administrator admitted the failure to ensure resident safety concerning the possession and management of smoking paraphernalia.
Failure to Protect Residents from Physical and Sexual Abuse
Penalty
Summary
The facility failed to protect the residents' right to be free from physical and sexual abuse, as evidenced by two incidents involving residents. In the first incident, Resident 12, who had dementia and a communication deficit, was found on the floor with multiple skin tears after an altercation with Resident 17, who had a history of physical aggression and dementia. Staff were aware of both residents' behavioral issues, including Resident 12's tendency to wander into other residents' rooms and Resident 17's aggressive response to personal space invasion. Despite this knowledge, the facility did not adequately monitor or intervene, resulting in Resident 12 being injured by Resident 17 during an altercation in Resident 17's room. Staff confirmed that Resident 12's fragile skin could easily tear from physical contact, which was evident in this incident. Both residents were unable to recall the altercation due to their cognitive impairments, but staff and a housekeeper witnessed the aftermath and confirmed the physical altercation and injuries sustained by Resident 12. The facility's failure to consistently check on Resident 12's whereabouts and intervene as necessary to protect residents' safety led to this incident of physical abuse. In the second incident, Resident 3, who was cognitively intact, reported that Resident 33, who also had dementia but was ambulatory, touched her/his breast inappropriately. Resident 3 stated that Resident 33 entered her/his room, made an inappropriate comment, and then grabbed her/his breast before leaving. This incident was witnessed by Resident 3's roommate, who confirmed the inappropriate touching. Resident 3 reported the incident to a nurse later that evening, and the nurse confirmed that Resident 3 did not exhibit any changes in mood or behavior following the incident. Resident 33 denied the inappropriate touching and did not recall the incident. The facility's failure to prevent this incident of sexual abuse highlights a lack of adequate supervision and intervention to protect residents from abuse by other residents.
Unsanitary Food Storage and Handling
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in one of its two kitchens, specifically the dining room kitchenette. During an initial tour, several issues were observed: a piece of cake with whipping cream was not covered, labeled, or dated; a small plastic container with an unknown substance was not labeled or dated; a covered plate with a pork chop, baked potato, and corn was not labeled or dated; a tray with multiple covered juice drinks was not labeled or dated; and an opened container of prune juice had spilled onto lower shelves and the floor. In the freezer, seven small plastic containers with unknown substances were not labeled or dated; two individual strawberry yogurt containers had a use-by date that had passed; two opened one-pint ice cream containers with resident names were not dated; an opened gallon of chocolate ice cream did not have a secure lid and was not dated; and three small plastic containers of fish snack crackers on top of the refrigerator were not labeled or dated. The administrator confirmed these items were not appropriately stored.
Failure to Accommodate Resident Lighting Needs
Penalty
Summary
The facility failed to ensure resident needs and preferences related to lighting were accommodated for one resident reviewed for accommodation of needs. Resident 13, admitted with diagnoses including a non-pressure chronic ulcer and Type 2 Diabetes, had moderately impaired cognition. The resident reported on multiple occasions that the overbed light switch had a short cord, making it inaccessible. Despite reporting this issue to staff, it remained unresolved. The Maintenance Director acknowledged the problem and stated that maintenance issues should be reported through the facility's work order system or via word of mouth. The Administrator confirmed that residents should be able to control their lighting and that the pull cord needed repair.
Failure to Obtain and Discuss Advance Directives
Penalty
Summary
The facility failed to obtain copies of advance directives and inform residents of their right to formulate advance directives for two residents. Resident 8, admitted in August 2017 with diagnoses including Type 2 Diabetes and morbid obesity, had a care plan indicating the presence of a Living Will or other Advance Directive. However, there was no evidence in Resident 8's health record that the facility obtained a copy of the advance directive or discussed it with the resident since the care plan intervention was initiated in June 2023. The facility administrator acknowledged this oversight during an interview on May 30, 2024. Similarly, Resident 13, admitted in March 2024 with diagnoses including a non-pressure chronic ulcer and Type 2 Diabetes, had no documentation in their health record indicating the presence of an advance directive or that staff discussed the creation of one with the resident. Despite the resident being their own responsible party and having moderately impaired cognition, the facility did not address the advance directive discussion. The administrator confirmed this lapse during the same interview on May 30, 2024.
Failure to Notify Resident's Representative of Out-of-Facility Appointment
Penalty
Summary
The facility failed to notify a resident's representative of an appointment out of the facility. Resident 289, who was admitted in December 2016 with diagnoses including chronic congestive heart failure and type 2 diabetes, had severe cognitive decline as noted in an 8/29/22 CAA. The resident's admission agreement indicated that her/his representative/legal guardian was her/his daughter. On 11/10/2022, Resident 289 was sent out of the facility for an appointment, but there was no evidence in the health record to indicate that the representative was notified. The Administrator acknowledged this lapse in notification on 6/3/24 at 2:16 PM.
Failure to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment for a resident admitted in March 2024 with diagnoses including a non-pressure chronic ulcer and type 2 diabetes. The resident's cognition was moderately impaired as per the Admission MDS reviewed on April 4, 2024. On May 29, 2024, a gouge approximately 16 inches in length and 36 inches above the floor was observed in the wall adjacent to the head of the resident's bed. The Maintenance Director acknowledged the gouge on June 3, 2024, and stated it should have been fixed prior to the resident moving into the room. The Administrator also stated that the gouge was unacceptable and that residents' rooms should be painted and homelike before they move in.
Failure to Provide Baseline Care Plans
Penalty
Summary
The facility failed to ensure that a written summary of a baseline care plan was provided to residents within 48 hours of admission for two of the four sampled residents. Resident 7, admitted with diagnoses including kidney failure and anxiety, did not have a baseline care plan reviewed or provided. Resident 7 confirmed not receiving a baseline care plan. Staff members, including an LPN and an RNCM, were unaware that baseline care plans needed to be provided and reviewed with residents. Similarly, Resident 241, admitted with diagnoses including heart failure and high cholesterol, also did not have a baseline care plan reviewed or provided. Staff members again confirmed their lack of awareness regarding the requirement to provide and review baseline care plans with residents.
Failure to Develop Comprehensive Care Plan for PTSD
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for a resident diagnosed with post-traumatic stress disorder (PTSD). The resident was admitted in January 2024, and the Mood State CAA from the resident's February 2024 Admission MDS noted the PTSD diagnosis and indicated that the care plan should address PTSD symptoms with interventions to assist with mood. However, a review of the resident's comprehensive care plan, last revised in April 2024, revealed no focus, goals, or interventions for the resident's PTSD symptoms. The Social Services Director confirmed that although a PTSD evaluation was completed, the comprehensive care plan related to PTSD symptoms was not completed.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to follow physician orders regarding wound care for a resident diagnosed with lymphedema and erythema. The physician's order from April instructed staff to apply ACE wraps to the resident's lower extremities in the morning and remove them at night. However, the Treatment Administration Record (TAR) for May showed that the ACE wraps were not applied on multiple dates. Additionally, the resident was observed wearing ragged ACE wraps that had not been removed for a week, contrary to the physician's orders. Staff confirmed that the resident was not wearing the ACE wraps as ordered during an observation on May 31.
Inadequate Care and Hazard Removal for Two Residents
Penalty
Summary
The facility failed to provide adequate care and hazard removal for two residents. Resident 239, admitted with diagnoses including obesity and dementia, had a care plan requiring two staff members to be present during care. However, on one occasion, only one staff member was present, resulting in the resident rolling out of bed. This was confirmed by both the CNA and the Administrator. Resident 240, admitted with severe cognitive impairment, was found with two unplugged electric burners on the floor of their room. The resident intended to use them, but staff were unaware of their presence until they were discovered and removed by the Administrator.
Failure to Maintain Oxygen Equipment and Administer Oxygen as Ordered
Penalty
Summary
The facility failed to maintain oxygen equipment and ensure oxygen was administered as ordered for two residents. Resident 4, who was admitted with multiple sclerosis and chronic obstructive pulmonary disease (COPD), was observed using an oxygen concentrator with a thick layer of dust on the external filter. Staff acknowledged that the filter was not clean, despite the expectation that external filters should be cleaned once a month. This observation was confirmed by both an LPN and the Director of Nursing Services (DNS). Resident 21, admitted with congestive heart failure and chronic respiratory failure, was observed using an oxygen concentrator with a flow rate of 2.5 liters, contrary to the physician's order of 1.5 liters. Additionally, the external filter on this concentrator also had a thick layer of dust. Staff acknowledged the discrepancy in the oxygen flow rate and the unclean filter. The DNS confirmed that oxygen levels should be checked at the beginning of each shift and filters cleaned monthly.
Failure to Accurately Document Wound Care
Penalty
Summary
The facility failed to accurately document wound care being provided in accordance with physician's orders for a resident with lymphedema and erythema. The resident was admitted in January 2018 and had normal cognitive function as of January 2024. A physician's order from April 2024 instructed staff to apply ACE wraps to both lower extremities in the morning and remove them at night. However, the Treatment Administration Record (TAR) for May 2024 showed that the ACE wraps were documented as being off on multiple dates, despite the resident stating that the same ACE wraps had been worn for a week without being removed at night. An observation on May 28, 2024, confirmed the resident was wearing ragged ACE wraps that were nearly falling off. Staff later confirmed that the records regarding the ACE wraps were not accurately documented.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
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Nursing homes near Portland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cascade Terrace Post Acute | 1 mi | ★★★★★ | 5 | 0 |
| Cedar Crossings | 1.2 mi | ★★★★★ | 14 | 0 |
| Secora Rehabilitation Of Cascadia | 1.5 mi | ★★★★★ | 0 | 0 |
| Gracelen Care Center | 1.6 mi | ★★★★★ | 5 | 0 |
| Portland Health And Rehabilitation | 1.8 mi | ★★★★★ | 21 | 0 |
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