Avamere Crestview Of Portland
Inspection history, citations, penalties and survey trends for this long-term care facility in Portland, Oregon.
- Location
- 6530 Sw 30th Avenue, Portland, Oregon 97239
- CMS Provider Number
- 385031
- Inspections on file
- 27
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Avamere Crestview Of Portland during CMS and state inspections, most recent first.
The facility failed to provide staff with cultural competency training, as required by its policy, impacting the care of a resident with dementia. Interviews revealed that CNAs and the staffing coordinator were unaware of any such training, and the administrator could not provide documentation of completed training.
The facility's kitchen had unsanitary conditions, including an ice machine draining onto the floor, moldy water, and a dirty ice scoop holster. A gap under a door could allow pests, and a dusty fan was blowing on clean dishes. The Dietary Manager acknowledged these issues and the need for regular cleaning.
The facility failed to follow infection control precautions, as a resident's catheter bag was observed dragging on the ground, and clean laundry was transported on an uncovered rack. The DNS confirmed the improper handling of the catheter bag, and the Regional Housekeeping Manager acknowledged that laundry racks should be covered.
The facility was found to have numerous maintenance issues affecting the homelike environment for residents. Observations included rooms with damaged doors, walls with gouges and missing paint, broken blinds, and peeling wall bases. Common areas also had rippled carpets, sharp edges, and stained furniture. These deficiencies were acknowledged by the facility's Administrator and Maintenance Director.
The facility failed to provide necessary social services and assessments for residents with PTSD, communication needs, and dental requirements. A resident with PTSD did not receive a trauma assessment or care plan, while another was not assisted with clothing or hearing needs. A resident with dementia was not provided an interpreter, and a malnourished resident was not offered dental services. These deficiencies indicate a lack of attention to residents' psychosocial and communication needs.
A resident with dysphagia and moderate cognitive impairment received insufficient calories from tube feeding due to a failure in adhering to physician orders and facility policies. The resident was prescribed 1500 calories daily via Nutren 2.0, but only received 1200 calories, as confirmed by the Regional Nurse Consultant. Additionally, a partially used and undated feeding bag was observed in the resident's room, indicating non-compliance with labeling and removal protocols.
A facility failed to ensure dignity for a resident with dementia by serving meals on Styrofoam dishware. The resident's care plan specified this practice, and observations confirmed its implementation. An LPN, the Dietary Manager, and the Administrator acknowledged the dignity concern, noting no attempts were made to use alternatives like plasticware.
A facility failed to obtain consent before administering antipsychotic medication to a resident with dementia and a fracture. The resident was prescribed valproic for schizoaffective disorder, and records showed daily administration without documented consent. A nurse confirmed the lack of documentation and consent.
A resident with blindness was observed wearing a hospital gown despite preferring pants, as staff did not offer dressing assistance. The resident required substantial help with dressing, and a CNA confirmed the resident's preference for pants. The facility administrator expected staff to assist residents with dressing in the morning.
A resident with malignant brain cancer and mild cognitive impairment reported that a night shift CNA was unresponsive and took away their call light, leading to a lack of care. The facility's DNS and LPN were aware of the incident but did not report it to the State Survey Agency or conduct a thorough investigation, despite acknowledging the potential for abuse.
A resident with malignant brain cancer and mild cognitive impairment reported that a night shift CNA was unresponsive and took away their call light, leading them to call their brother for help. The DNS and LPN Resident Care Manager were informed, and the resident's care plan was updated, but the facility failed to investigate the allegation of abuse, as the CNA was not interviewed and the complaint was not thoroughly examined.
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in dental and communication needs. One resident with chronic health issues had significant dental problems not reflected in their MDS due to reliance on a previous assessment. Another resident with dementia was inaccurately assessed for language needs, as assessments were conducted without an interpreter, leading to communication barriers.
A facility failed to incorporate PASARR Level II recommendations into a resident's care plan and assessments. The resident, with mental health disorders, was evaluated and recommended to participate in support groups and have a daily plan for managing difficult situations. These recommendations were not followed, as confirmed by staff interviews.
A facility failed to complete a comprehensive baseline care plan within 48 hours for a resident with anxiety, depression, and a history of mental disorders. The resident experienced distress when a CNA did not provide care and removed their call light, triggering memories of past trauma. No assessment of the resident's mental health or behavioral history was conducted, leading to the deficiency.
The facility failed to update care plans for two residents, one with dysphagia and another with a pressure ulcer. A resident with dysphagia was observed using a straw and eating in their room, contrary to their care plan. Another resident had a stage 2 pressure ulcer not included in their care plan, despite a physician's order for daily care. Staff acknowledged the need for care plan revisions.
A resident with dementia and a primary language of Laotian or Thai did not receive appropriate communication services at the facility. Despite the care plan's instruction to use interpreter services, staff communicated with the resident in English using yes-or-no questions, which the resident did not understand. This failure to use interpretive interventions placed the resident at risk for diminished quality of life and potential decline in daily living activities.
A facility failed to provide adequate assistance with ADLs for a resident with severe cognitive impairment. The resident, who required substantial help with dressing, was observed wearing the same clothes for multiple days. Staff confirmed that the resident was only changed if their clothes became dirty, contrary to the facility's expectations for daily dressing in clean clothes.
Three residents with dementia were not provided with a person-centered activity program, leading to a diminished quality of life. One resident was isolated without access to preferred activities like reading and music, another was left in bed without sensory engagement, and a third faced language barriers and was not involved in activities. Staff were unaware of residents' interests, and the Activity Director admitted to not facilitating activities that matched residents' preferences.
A resident with a hearing deficit and moderate cognitive impairment was not provided with necessary auditory consults or resources for a hearing aid, despite physician orders and expressed interest. The facility's staff failed to communicate and follow procedures, resulting in unmet hearing needs.
The facility failed to provide trauma-informed care for three residents with PTSD, as required by their policy. Despite the need for universal trauma screening and individualized care plans, no assessments or care plans were found in the records of these residents. Staff acknowledged that trauma screenings should have been completed at admission, especially for those with PTSD.
The facility failed to properly store biologicals, as two expired Pfizer COVID-19 vaccines were found in the medication refrigerator. This was confirmed by a CMA and the DNS, posing a risk of unsafe access to residents.
A facility failed to provide routine dental services to a resident with severe protein calorie malnutrition, who had no natural teeth and expressed interest in new dentures. Despite a physician order to schedule dental consultations, no evidence was found that dental needs were addressed. Both the Social Services Director and an LPN confirmed that dental services were not offered, and the Administrator could not provide further information.
A resident with hemiplegia was discharged with inaccurate documentation regarding their skin condition, leading to a deficiency. Despite having documented pressure ulcers and excoriation during their stay, the discharge summary incorrectly stated no skin impairments. Upon arrival at an adult foster home, a stage 2 pressure ulcer was observed, contradicting the facility's records. Staff were unable to confirm the presence of pressure ulcers, and no home health wound care was ordered due to a lack of awareness of the resident's needs.
A facility failed to assess and update the care plan for a pressure ulcer on a resident's right ear. The resident, with a history of stroke, had a physician's order for daily care of the ulcer, but no care plan or wound assessment was documented. Observations noted a stage 2 pressure ulcer, and an LPN confirmed the lack of documentation and attributed the ulcer to the resident's inability to reposition themselves.
Lack of Cultural Competency Training for Staff
Penalty
Summary
The facility failed to ensure that its staff had the appropriate competencies and skills to maximize the well-being of residents, specifically in the area of cultural competency. This deficiency was identified during a review of a resident admitted in 2016 with dementia. Interviews with staff members revealed that a CNA who had been employed for over a year and another CNA with several years of service had not received any cultural competency training. Additionally, the staffing coordinator was unaware of any such training program at the facility. The facility's administrator was unable to provide documentation proving that the staff had received the required cultural competency training, despite the facility's policy indicating that all staff should receive orientation and in-service training in this area.
Unsanitary Conditions in Kitchen Areas
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in its kitchen, specifically in the ice machine, dry storage, and dish drying areas. Observations revealed that the ice machine was draining onto the floor, causing a puddle of brown, moldy water to form, which flowed under the linoleum and into the path to the walk-in freezer. A brown porous substance was found under the ice machine, which the Dietary Manager identified as wadded-up paper towels used to collect water. Additionally, the ice scoop holster on the ice machine contained an accumulation of water and a brown slimy substance, indicating it was not cleaned as required. Further observations noted a half-inch gap under the exit door adjacent to the dry storage area, which the Dietary Manager acknowledged could allow pests to enter the facility. A large drum fan was also observed blowing on a shelving unit with clean dishes, with the fan's grate covered in fuzz, grime, and dust, potentially contaminating the clean items. The Dietary Manager admitted the unsanitary conditions and the need for regular cleaning to prevent contamination in the kitchen and food prep areas.
Infection Control Lapses in Catheter Care and Laundry Handling
Penalty
Summary
The facility failed to adhere to proper infection control precautions in two observed instances, placing residents at risk for cross-contamination and infection. In the first instance, a resident with a history of urinary tract infection was observed ambulating independently in a wheelchair with their catheter bag dragging on the ground. This was confirmed by the Director of Nursing Services (DNS) as improper practice, as catheter bags should not contact the floor. In the second instance, a housekeeping staff member was seen pushing an uncovered rolling rack of clean resident clothing down a crowded hallway, leaving it unattended while delivering items to resident rooms. The staff member and the Regional Housekeeping Manager confirmed that the rolling racks used for clean clothing should be covered, which was not the case during the observation.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment for residents, as evidenced by numerous maintenance issues observed in various rooms and common areas. Specifically, several resident rooms had doors with missing pieces of wood and sharp edges, walls with gouges, missing paint, and exposed drywall. Additionally, some rooms had broken blinds, large scratches on walls, and peeling wall bases. These deficiencies were noted in rooms 20, 23, 24, 27, 33, 35, 36, 38, 40, 45, 46, 49, 60, 61, 62, 64, 65, 66, 68, and 69, among others. Common areas also exhibited significant maintenance issues, including rippled carpets outside certain rooms, pulled-away carpets at the nurses' stations, and sharp edges with missing paint and exposed drywall. The alcove adjacent to Hall 70 had dirty light fixtures and stained chairs with exposed substrate fabric. The main dining room had blinds with missing and broken slats, and the entryway had a sharp, jagged wall edge. These conditions were acknowledged by the facility's Administrator and Maintenance Director, indicating a recognition of the need for repairs.
Failure to Provide Adequate Social Services and Assessments
Penalty
Summary
The facility failed to provide medically-related social services to ensure the highest practicable mental and psychosocial well-being for several residents. Resident 7, who was admitted with PTSD, did not have a comprehensive assessment of their mental and psychosocial needs, including trauma and potential triggers. The Social Services Director acknowledged that trauma assessments were not completed for residents admitted before July 2024, which included Resident 7. Resident 34, a Vietnam War veteran with PTSD, was not assessed for trauma, and no care plan was developed to address potential triggers. The resident, who was visually impaired and had moderate hearing difficulty, was not offered an auditory consult or assistance in obtaining a hearing device. Additionally, the resident expressed a preference for clothing over a hospital gown, but staff did not assist in obtaining clothing, leaving the resident with limited personal items. Resident 51, also with PTSD, did not receive a trauma assessment or care plan for potential triggers. Resident 20, with dementia, preferred communication in their primary language, but the facility did not arrange for an interpreter. Resident 46, diagnosed with severe protein-calorie malnutrition, expressed a need for new dentures to aid in eating, but the Social Services Director had not arranged for dental services. These deficiencies highlight the facility's failure to meet the residents' psychosocial and communication needs.
Inadequate Enteral Feeding Management
Penalty
Summary
The facility failed to provide appropriate care and services related to enteral feeding for a resident with dysphagia, who was moderately cognitively impaired and relied on a feeding tube for more than 51 percent of their caloric intake. The resident was prescribed Nutren 2.0 at an infusion rate of 75 ml per hour for eight hours to provide 1500 calories daily, starting at 8:00 PM. However, the resident's Treatment Administration Record (TAR) indicated they received only 600 ml of Nutren 2.0 each day, equating to 1200 calories, which was confirmed by the Regional Nurse Consultant as insufficient compared to the physician's order. Observations revealed that a partially used and undated bag of Nutren 2.0 was left hanging from the resident's IV pole, contrary to the facility's policy requiring labeling with initials, date, and time. Staff interviews indicated a misunderstanding of the caloric content, with one LPN incorrectly stating that 600 ml equaled 1500 calories. The facility's policy also required the removal of used feeding bags immediately after use, which was not adhered to, as evidenced by the presence of the undated bag in the resident's room. This oversight placed the resident at risk for nutritional complications and weight loss.
Dignity Concern Due to Use of Styrofoam Dishware
Penalty
Summary
The facility failed to ensure dignity for a resident diagnosed with dementia, who was admitted in March 2022. The resident's Annual MDS completed in March 2024 indicated significant cognitive impairment. The resident's care plan, revised in August 2024, specified that meals were served on Styrofoam dishware. Observations from September 9 to September 11, 2024, confirmed that the resident ate meals off Styrofoam dishware. On September 12, 2024, an LPN stated that the facility had not attempted to implement alternatives such as plasticware and confirmed the loss of dignity associated with using Styrofoam dishware. The Dietary Manager and the Administrator also acknowledged the dignity concern related to the use of Styrofoam dishware.
Failure to Obtain Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to obtain consent before administering antipsychotic medication to a resident, which was identified during an interview and record review. The deficiency involved a resident who was admitted with diagnoses including a fracture and dementia. The resident was prescribed valproic for schizoaffective disorder as per the physician's order dated July 2024. The medication administration records for August and September 2024 showed that the resident received valproic daily. However, a review of the resident's health record revealed no documentation indicating that the resident was informed of the risks and benefits of the medication. On September 11, 2024, a registered nurse case manager confirmed the absence of documentation and acknowledged that consent was not obtained from the resident or their representative before starting the medication.
Failure to Honor Resident's Clothing Preference
Penalty
Summary
The facility failed to honor a resident's preference for clothing, impacting their right to self-determination. Resident 34, admitted in October 2023 with a diagnosis of blindness, was observed wearing a hospital gown on multiple occasions despite expressing a preference for wearing pants. The resident's admission MDS indicated a severe visual impairment and a need for substantial assistance with dressing, while the care plan noted total dependence on staff for dressing. Despite this, the resident reported that staff did not offer assistance to get dressed. A CNA confirmed that the resident never refused assistance and preferred wearing pants. The facility administrator stated that staff were expected to offer dressing assistance in the morning.
Failure to Report Alleged Abuse to State Survey Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Survey Agency concerning a resident who was admitted with malignant brain cancer and mild cognitive impairment. The resident expressed concerns about a night shift CNA who was unresponsive to the call light and unfriendly during care. The resident reported that the CNA took away the call light, forcing the resident to call a family member for assistance. The facility's DNS and LPN Resident Care Manager were aware of the resident's concerns and updated the care plan, deciding that the CNA would no longer work with the resident. Despite the resident's report of the call light being taken away, which could potentially be considered abuse, the facility did not conduct a thorough investigation or report the incident to the State Survey Agency. The DNS acknowledged that the incident could have been abuse depending on the circumstances but did not interview the CNA involved. The RNCM confirmed that a Facility Incident Report should have been completed and sent to the State Survey Agency if abuse was suspected.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse involving a resident who was admitted with malignant brain cancer and mild cognitive impairment. The resident expressed concerns about a night shift CNA who was unresponsive to the call light and unfriendly during care. The resident reported that the CNA took away the call light, leaving them to call their brother for assistance. The DNS and LPN Resident Care Manager were informed of these concerns and spoke with the resident and their family. The resident's care plan was updated, and it was decided that the CNA would no longer work with the resident. Despite the serious nature of the allegation, the facility did not conduct a thorough investigation into the incident. The DNS acknowledged that the removal of the call light could potentially constitute abuse, depending on the circumstances. However, the CNA involved was not interviewed, and the complaint was not investigated to rule out abuse. This lack of investigation placed residents at risk for abuse and neglect, as the facility did not take appropriate steps to address the allegation and ensure resident safety.
Inaccurate Assessments for Dental and Communication Needs
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in communication, dental, and activities assessments. Resident 11, admitted with chronic diastolic heart failure and chronic respiratory failure, was observed to have significant dental issues, including gray and jagged teeth, despite being recorded as having no oral or dental issues in the annual MDS. The resident had been using a medicated mouthwash for oral infections, which was not reflected in the MDS due to the MDS Coordinator's reliance on a previous dental assessment where the resident refused an oral inspection. This oversight resulted in the resident's dental needs not being accurately captured or addressed. Resident 20, diagnosed with dementia, was inaccurately assessed regarding their primary language and communication needs. The resident's MDS indicated English as the primary language and a preference for an interpreter, while the Social Determinant of Health Assessment noted Laotian or Thai as the primary language. Staff confirmed that assessments were conducted without an interpreter, leading to communication barriers and inaccurate documentation of the resident's needs. The facility's failure to use interpretative services during assessments contributed to the deficiency in accurately capturing the resident's communication requirements.
Failure to Incorporate PASARR Level II Recommendations
Penalty
Summary
The facility failed to incorporate PASARR Level II recommendations into the assessments and care plans for a resident with mental health disorders, including post-traumatic stress disorder, depression, and anxiety. The resident was admitted with these diagnoses and had a PASARR Level II Mental Health Evaluation conducted, which recommended participation in support groups for stroke survivors and a daily plan to help manage difficult situations. Despite these recommendations, the facility did not integrate them into the resident's care plan or assessments. This oversight was confirmed during interviews with the Social Services Coordinator and acknowledged by the Administrator and Regional Nurse Consultant, who admitted there was no follow-up on the recommendations.
Failure to Complete Baseline Care Plan
Penalty
Summary
The facility failed to complete a comprehensive baseline care plan within 48 hours of admission for a resident with a history of anxiety, depression, and mental and behavioral disorders. Upon admission, the resident experienced an incident where a night shift CNA did not provide care and removed the resident's call light, leading the resident to call a family member for assistance. This incident caused the resident significant distress, as it reminded them of past childhood trauma. A review of the resident's chart revealed no assessment of their mental health or behavioral history had been conducted, contributing to the deficiency.
Failure to Revise Care Plans for Residents with Specific Needs
Penalty
Summary
The facility failed to revise care plans for two residents, leading to potential risks for unmet needs. Resident 28, who was readmitted with dysphagia and required specific dining safety measures, was observed eating in her room with a straw, contrary to her care plan that specified no straw use and dining in the atrium. Staff confirmed that the resident regularly used a straw without issue, indicating a need for care plan revision, which was acknowledged by the Director of Nursing Services and the Regional Nurse Consultant. Resident 19, admitted with a history of stroke, had a physician's order for daily care of a pressure ulcer on the right ear, but this was not reflected in the care plan. Observations confirmed the presence of a stage 2 pressure ulcer, attributed to the resident's inability to reposition themselves. The LPN Resident Care Manager acknowledged the omission of the wound care in the resident's care plan, highlighting a failure to update the care plan to address the resident's current condition.
Failure to Provide Appropriate Communication Services
Penalty
Summary
The facility failed to provide appropriate treatment and services in communication for a resident with a language barrier. The resident, admitted in 2016 with a diagnosis of dementia, primarily spoke Laotian or Thai. The care plan dated June 28, 2024, indicated that staff should use Optimal Interpreter Services to assist in communication. However, the annual MDS completed on June 29, 2024, incorrectly listed English as the resident's primary language, although it noted the need for an interpreter for communication with healthcare staff. The Communication CAA completed on June 19, 2024, confirmed that language was a concern, identifying Laotian or Thai as the primary language. During observations on September 9, 11, and 12, 2024, staff communicated with the resident using yes-or-no questions in English, which the resident did not respond to, indicating a lack of understanding. Staff 14, a CNA, admitted to not using interpretive interventions with the resident. The facility administrator was informed of these findings on September 13, 2024, but did not provide any additional information. This lack of appropriate communication placed the resident at risk for diminished quality of life and potential decline in their ability to perform activities of daily living.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to ensure that a dependent resident received appropriate assistance with activities of daily living (ADLs). Resident 33, who was readmitted to the facility in June 2022 with a diagnosis of dementia, was identified as severely cognitively impaired and required substantial assistance with dressing. The resident's care plan indicated the need for assistance from one staff member to get dressed. However, observations on September 9, 11, and 12, 2024, revealed that the resident was wearing the same clothes for multiple days, as confirmed by Staff 25, the assigned CNA. Staff 25 stated that the resident was only changed if their clothes became dirty. The facility administrator acknowledged these findings and stated that staff were expected to assist residents in getting dressed each morning in clean clothes.
Failure to Provide Person-Centered Activity Program
Penalty
Summary
The facility failed to provide a person-centered activity program for three residents, leading to a diminished quality of life. Resident 7, admitted with dementia, had preferences for reading, listening to music, and playing games, but was observed to be isolated in their room without access to these activities. Despite having interests in documentaries, classical music, and outdoor activities, the resident was not engaged in any group activities and was unaware of the books available in their room. Staff members were unaware of the resident's interests, and the Activity Director admitted to missing the resident's interest in going outside and not reattempting activities like Bingo after the resident received an assistive hearing device. Resident 33, also with dementia, was severely cognitively impaired and had interests in music, pet visits, and being outside. However, the resident was mostly observed in bed with a stuffed cat, without access to music or reading materials, and the bird feeder outside their window was not visible. The Activity Director acknowledged that the resident no longer self-initiated activities and had not participated in group activities or gone outside in the past year. Staff members confirmed the resident's lack of participation in activities and the absence of sensory activities attempted by the Activity Director. Resident 20, with dementia and a language barrier, preferred watching funny videos and listening to music but was observed in bed with English language programming on the television, despite their primary language being Laotian or Thai. The resident did not participate in any group or one-to-one activities, and staff confirmed the resident spent most of their time in bed. The facility's failure to engage these residents in meaningful activities and address their individual preferences and needs contributed to the deficiency.
Failure to Provide Hearing Services
Penalty
Summary
The facility failed to ensure that a resident with a hearing deficit received necessary treatment and services to maintain their hearing abilities. The resident, admitted in October 2023 with diagnoses including blindness, was found to have moderate cognitive impairment and moderate difficulty hearing. Despite the resident's communication care plan indicating a hearing deficit and physician orders for auditory consults as needed, there was no evidence in the clinical record that an auditory consult or resources for obtaining a hearing aid were offered. During an observation, the resident was found with the television volume turned up loud, indicating potential hearing difficulties, and expressed that they had never been offered an auditory consult or resources for a hearing device, despite being interested. Interviews with facility staff revealed a breakdown in communication and procedure. The Social Services Director stated that auditory consults were scheduled when informed by nursing staff, but no request had been made for this resident. The Director of Nursing Services and the LPN-Resident Care Manager acknowledged the oversight, with the LPN confirming the resident's hearing impairment and admitting that the opportunity for an auditory consult had not been offered. This lack of action placed the resident at risk for unmet hearing needs.
Failure to Provide Trauma-Informed Care for PTSD Residents
Penalty
Summary
The facility failed to provide trauma-informed care for three residents who were identified as trauma survivors, all diagnosed with PTSD. The facility's policy required universal screening for trauma exposure and the development of individualized care plans to address trauma triggers. However, for Resident 7, who had a military history and exposure to Agent Orange, there was no evidence of a trauma assessment or care plan in their clinical record. Staff acknowledged that trauma screenings should have been completed at admission, especially for residents with PTSD. Similarly, Resident 34, a Vietnam War Veteran with PTSD, reported that no one at the facility had discussed their PTSD or potential triggers. Despite being moderately cognitively impaired, the resident expressed interest in discussing their condition. No trauma assessment or care plan was found in their record. Resident 51, admitted with PTSD and anxiety, also lacked a trauma assessment and care plan. Staff confirmed that trauma screenings were expected at admission for all residents, particularly those with PTSD, but this was not done for these residents.
Improper Storage of Expired COVID-19 Vaccines
Penalty
Summary
The facility failed to ensure the proper storage of biologicals in the medication room, as observed during a random check for medication storage. Two Pfizer COVID-19 vaccines were found in the medication refrigerator with an expiration date that had already passed. This was confirmed by both a Certified Medication Aide (CMA) and the Director of Nursing Services (DNS), who verified that the vaccines were indeed expired. This oversight placed residents at risk of unsafe access to stored biologicals.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to ensure routine dental services were provided for a resident reviewed for dental care needs, placing them at risk for unmet dental needs. The resident was admitted with a diagnosis of severe protein calorie malnutrition and had no natural teeth, tooth fragments, or missing teeth as per the Admission Nursing Database assessment. A physician order instructed the facility to schedule dental consultations as indicated, but no evidence was found in the clinical record that additional dental needs were offered. The resident expressed interest in new dentures to facilitate eating, but both the Social Services Director and the LPN Resident Care Manager confirmed that dental services were not offered. The Administrator was unable to provide additional information regarding the resident being offered dental services.
Inaccurate Discharge Documentation of Resident's Skin Condition
Penalty
Summary
The facility failed to ensure accurate documentation and communication of a resident's skin condition at the time of discharge, leading to a deficiency. Resident 261, who was admitted with hemiplegia, had documented skin issues during their stay, including pressure ulcers and excoriation on the buttocks. Despite these documented issues, the discharge skin summary inaccurately stated that the resident had no skin impairments, and the discharge summary only mentioned treatment orders for A&D cream to the lower extremities, omitting any mention of the buttocks. Furthermore, the discharge MDS incorrectly indicated that the resident did not have any pressure ulcers. Upon discharge to an adult foster home, a public complaint was filed, accompanied by a photograph showing open areas on the resident's buttocks, contradicting the facility's discharge documentation. Witnesses, including a registered nurse, confirmed observing a stage 2 pressure ulcer on the resident's coccyx upon arrival at the foster home. Facility staff, including an RNCM and an LPN, were unable to recall or confirm the presence of pressure ulcers at the time of discharge, and there was no documentation of wound assessments. Additionally, the social services staff confirmed that no home health wound care was ordered due to a lack of awareness of the resident's needs, further highlighting the communication breakdown and documentation inaccuracies at discharge.
Failure to Assess and Update Care Plan for Pressure Ulcer
Penalty
Summary
The facility failed to assess and update the care plan for a pressure ulcer on a resident's right ear. The resident, who was admitted in 2016 with a diagnosis of stroke, had a physician's order dated 8/23/24 for daily cleaning and monitoring of a pressure sore on the right ear. However, a review on 9/10/24 revealed no care plan or wound assessment for this pressure ulcer in the resident's medical record. Observations on 9/11/24 noted the presence of a red, raised wound with a scab, resembling a stage 2 pressure ulcer. Staff 12, an LPN Resident Care Manager, confirmed the absence of the wound in the care plan and the lack of documented wound assessments, attributing the ulcer to the resident's inability to reposition themselves, causing pressure on the ear.
Latest citations in Oregon
A resident with acute respiratory failure and heart failure had a documented Full Code status and a POLST specifying Attempt Resuscitation/CPR and Full Treatment. During night rounds, two CNAs found the resident not breathing, cool to the touch, with yellow skin and no pulse, but did not initiate CPR or call a code blue, instead going to notify an LPN. The LPN assessed the resident, confirmed absence of vital signs, noted the body was cold with mottling and no rigor mortis, and contacted the DNS, physician, and 911 for the coroner’s number, but did not start CPR or activate a code blue. No lifesaving measures were attempted despite facility policy requiring CPR for unresponsive residents without a valid DNR and the resident’s clearly documented full code status, leading surveyors to cite Immediate Jeopardy and substandard quality of care.
A resident with respiratory failure and pneumonia, who was Full Code and not on hospice, was found during routine rounds and suspected to be deceased. Nursing staff assessed the resident, noted there was no rigor mortis, confirmed death, and did not initiate a code blue or any resuscitation efforts despite the resident’s Full Code status. The facility later treated this as a potential neglect incident but did not report it to the State Agency within the required two-hour timeframe, as confirmed by the regional QA director.
A resident with chronic pain and a left below-knee amputation, who required supervision or touching assistance with ADLs, was discharged after returning from an outing shortly after midnight. Although discharge instructions noted the need for assistance and assistive devices, there was no documentation of referrals for medical equipment or home health services. Facility staff documented that the resident was discharged because they were out past midnight and believed Medicare would not cover the stay, did not issue a NOMNC, and recorded the discharge as voluntary despite the resident later reporting they had been “kicked out” and were sleeping on a friend’s couch with difficulty getting around. Staff interviews revealed no financial issues and indicated the resident had originally been scheduled for discharge at a later date.
A resident with a hip fracture and anxiety reported to social services that a CNA had been rough, told the resident to take themself to the bathroom, and instructed them not to get out of bed until a specified early morning time. The allegation was received by facility staff in the late afternoon, but the incident report was not submitted to the State Agency until the following day, exceeding the required 2-hour reporting timeframe acknowledged by the DNS. The deficiency concerns this untimely reporting of an abuse allegation, despite the CNA’s denial of any abuse.
A resident with hemiplegia, previously evaluated as not appropriate to self-administer any medications, was found to have open tubes of antifungal cream, anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) stored in a bedside drawer. Record review showed there were no MD orders for several of these topical products and no order permitting self-administration. An RN case manager confirmed the absence of orders, and the resident reported self-administering the medications, demonstrating a failure to ensure medications were administered only as ordered and in accordance with the resident’s assessed ability.
A resident with hemiplegia, previously evaluated as not appropriate to self-administer medications, was found with open containers of anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) in a bedside drawer. Record review showed no MD orders, no documented indication for use, and no monitoring for these medications. An RN case manager confirmed there were no orders and that staff did not administer or monitor the creams, while the resident reported self-administering them.
The facility failed to investigate multiple staff-reported allegations that one cognitively intact, wheelchair-using resident engaged in sexually inappropriate behaviors toward three other residents with significant cognitive and neurological impairments. Staff reported finding a resident with a ripped brief, crying and resisting care, and suspected sexual contact; they also reported that the alleged aggressor tried to take another resident into a shower room for sexual acts, attempted to video and kiss that resident, and encouraged a third resident to remove their top while present with a phone. CNAs, social services, and other staff stated they informed the administrator, DNS, HR, and unit management about these incidents and behaviors, but the administrator acknowledged that no investigations were conducted, despite being aware of the reports.
A resident with multiple sclerosis, care planned as dependent on two staff and requiring a Hoyer lift for transfers, was instead transferred by a CNA using a stand-pivot method without the lift or a second staff member. The CNA reported she had not read the resident’s care plan and described performing the transfer by giving the resident a “giant bear hug” and making several attempts to move the resident from chair to bed. The resident reported right flank pain and stated the transfer caused three broken ribs, although an x-ray later showed no rib fractures or dislocation and no visible injury was noted.
A resident with multiple sclerosis was admitted with physician orders for PT and OT, but review of the clinical record showed no documentation that these therapies were ever provided. The resident reported not receiving any therapy since admission, and the Director of Rehabilitation confirmed that no therapy services had been delivered during this period despite active orders, resulting in a failure to provide ordered rehabilitative services.
A dependent resident with dementia and a history of stroke, identified on the MDS as requiring staff assistance for showers, did not consistently receive scheduled bathing, and one CNA falsely documented that bathing had been provided. CNA task reports showed missed or undocumented baths on scheduled days, and an internal investigation confirmed that a bath recorded as completed on one date had not actually occurred. Staff interviews indicated that if bathing was not documented it usually did not occur, and that scheduled bathing was expected to be provided by staff.
Failure to Initiate CPR for a Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide CPR in accordance with a resident’s documented full code status. The facility’s Emergency Procedure CPR policy, initiated in 2001, required staff trained in CPR to initiate resuscitation on unresponsive residents who were not breathing unless there was a valid DNR order or clear signs of irreversible death such as rigor mortis. The policy further specified that if a resident’s DNR status was unclear, CPR should be started and continued until a DNR was confirmed. Resident 3 had been admitted with diagnoses including acute respiratory failure and heart failure and had a care plan and POLST on file indicating Full Code/Attempt Resuscitation and Full Treatment, including use of intubation, advanced airway interventions, mechanical ventilation, and transfer to hospital or ICU if indicated. On the night of the incident, a CNA (Staff 5) documented last vital signs for the resident at approximately 10:45 PM, with oxygen saturation of 92% on one liter of oxygen. At 2:00 AM, the resident was observed sleeping, breathing, and with a dry brief. Around 4:00 AM, Staff 5 and another CNA (Staff 8) entered the resident’s room and observed that the resident was not breathing, had yellow skin color, was cool to the touch, and had no palpable pulse. Both CNAs concluded the resident was deceased and went to notify the LPN (Staff 4) instead of initiating CPR or calling a code blue, despite having recent CPR training and later stating that, in retrospect, they would have started CPR and called for a code blue. When Staff 4 (LPN) entered the room, she assessed the resident and found no pulse, blood pressure, or respirations, noted the body was cold, with some mottling on the lower legs, pale/yellowish skin color, and no rigor mortis. Staff 4 did not initiate a code blue or CPR and instead contacted the DNS (Staff 2) and the physician, and then called 911 to obtain the coroner’s phone number. No lifesaving measures were attempted by any staff, despite the resident’s documented full code status and the facility policy requiring CPR in the absence of a valid DNR or signs of irreversible death. The DNS later stated she expected staff to call a code blue immediately, start CPR, call 911, and verify the resident’s code status. Surveyors determined that the facility failed to provide CPR according to the resident’s code status, placing all residents with full code status at risk and constituting substandard quality of care, with the noncompliance cited as Immediate Jeopardy and Past Noncompliance.
Removal Plan
- Administrator, DNS and nursing staff would be re-educated on the code blue process, how to locate a resident's code status in PCC and the POLST on file, and the importance of following individual resident care plans and orders.
- Resident code status would be cross-referenced with the PCC order, POLST scanned in binder, care plan, and resident dashboard.
- DNS or designee would monitor resident code status preferences for new admissions/returning admissions from hospitalizations.
- DNS or designee would audit code status for all new admissions and readmissions from hospitalization or ED visits, and share audit results with the QAPI committee to ensure substantial compliance is maintained.
- DNS or designee would complete a mock code.
- DNS or designee would complete mock codes.
Failure to Timely Report Alleged Neglect Involving Lack of CPR for Full Code Resident
Penalty
Summary
The facility failed to timely report an allegation of potential neglect related to CPR to the State Agency for one resident. The resident was admitted in February 2026 with diagnoses including respiratory failure and pneumonia and had a Full Code status, was not on hospice, and therefore was to receive CPR if found unresponsive. According to the facility’s investigation dated six days after the resident’s death, staff found the resident during routine rounds and suspected the resident was deceased, notified the nurse, and the nurse confirmed the resident was deceased. The investigation documented that at the time of the nurse’s assessment the resident did not have rigor mortis, yet the nurse did not initiate a code blue or any resuscitation interventions despite the Full Code status. The incident, which occurred on an identified date, was not reported to the State Agency until a later identified date, and the Regional Director of Quality Assurance confirmed that the facility did not report the incident within the required two-hour timeline. This failure to timely report the allegation of potential neglect involving the lack of CPR initiation for a Full Code resident constituted the deficiency identified by surveyors.
Failure to Ensure Safe and Orderly Discharge After Late Return from Outing
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and orderly discharge for a resident who was admitted with chronic pain, a left below-knee amputation, and post-surgical aftercare needs. An admission MDS completed shortly after admission documented that the resident was cognitively intact but required supervision or touching assistance with toileting, transfers, and bathing. Discharge instructions indicated the resident was being discharged home and that the resident’s current physical status required assistance and assistive devices, yet there was no documentation of referrals for needed medical equipment or a home health referral. The facility’s records did not show that these services or equipment were arranged prior to discharge. On the night in question, a nursing note documented that the resident returned to the facility after an outing at 12:23 AM, after the facility had notified the police because the resident’s location was unknown. The resident reported having been out with friends and being unaware of any concern. A social services note stated that because the resident was out past midnight, the resident was discharged from the facility, and a NOMNC was not issued because the resident left prior to the scheduled discharge and on their own initiative. A discharge summary documented that discharge instructions were reviewed with the resident, who refused to sign and was leaving voluntarily, and the voluntary consent form included a handwritten statement that the resident refused to sign. Later, the resident stated they had been “kicked out” for coming back late and were sleeping on a friend’s couch, finding it difficult to get around. Staff interviews showed there were no financial issues documented, that staff believed Medicare would not cover the resident if out past midnight, and that the resident had been scheduled for discharge several days later, while a regional director later characterized the situation as a clerical error and confirmed a normal discharge should have been completed.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to timely report an allegation of abuse to the State Agency after a resident reported that a CNA had been rough and verbally directive with them. The resident, who had been admitted with diagnoses including a hip fracture and anxiety, stated that the CNA was “kind of rough,” told the resident to take themself to the bathroom, and instructed the resident not to get out of bed until 6:00 AM. The resident reported this allegation of abuse involving the CNA to the social services staff member at 4:00 PM on 1/29/26. According to the facility’s investigation documentation, the allegation was received by staff at 4:00 PM on 1/29/26, and the Facility Reported Incident form was not received by the State Agency until 2:13 PM on 1/30/26. The DNS acknowledged that the facility became aware of the allegation at 4:00 PM on 1/29/26 and that it should have been reported to the State Agency within two hours but was not. The CNA denied abusing the resident or any resident, but the deficiency centers on the delay in reporting the allegation to the State Agency within the required timeframe.
Failure to Prevent Unauthorized Self-Administration of Non-Prescribed Medications
Penalty
Summary
Surveyors identified that a resident was self-administering non-prescribed topical medications despite a documented determination that they were not appropriate to self-administer any medications. The resident, admitted with hemiplegia, had a Self-Medication Administration Evaluation dated 11/13/25 indicating they were not appropriate to self-administer medications. During an observation on 3/19/26 at 7:50 AM with a RN case manager, open tubes of antifungal cream, anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) were found in the resident’s bedside table drawer. Review of the clinical record showed there were no physician orders for the anti-itch cream, hydrocortisone cream, or DMSO, and the resident did not have an order to self-administer any medications. The RN case manager confirmed the lack of orders for these medications, and at 8:10 AM the resident stated they did self-administer the medications found in their room. This constituted a failure by the facility to ensure the resident did not self-administer non-prescribed medications and to provide treatment and care according to physician orders and the resident’s evaluated ability to self-administer medications.
Unmonitored Self-Administration of Topical Medications Without Physician Orders
Penalty
Summary
The facility failed to ensure a resident’s drug regimen was free from unnecessary drugs by not providing adequate monitoring, indication for use, or physician orders for multiple medications. A resident admitted with hemiplegia in May 2024 had a self-medication administration evaluation dated 11/13/25 indicating they were not appropriate to self-administer any medications. During an observation on 3/19/26, an RN case manager found an open tube of anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) in the resident’s bedside table drawer. Record review showed no physician orders, no documented indication for use, and no monitoring for these medications. The RN case manager confirmed the resident did not have orders for the anti-itch cream, hydrocortisone cream, or DMSO, and that staff did not administer or monitor these medications. The resident stated they self-administered the medications found in their room, despite the prior evaluation determining they were not appropriate to self-administer any medications.
Failure to Investigate Multiple Allegations of Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to investigate multiple allegations of sexual abuse involving three residents. Resident 102, who had cognitive loss equivalent to a young child, legal blindness, and was non-verbal, was reportedly found with a ripped brief, crying, and resisting a brief change. Staff reported concerns that another resident, Resident 105, had performed or attempted to perform sexual acts on Resident 102. Staff members, including CNAs and social services, stated they informed facility management, including the Administrator and DNS, about the torn brief, Resident 102’s distress, and concerns that Resident 105 was being sexually inappropriate with multiple residents. Despite these reports and discussions in morning meetings, the Administrator acknowledged that no investigation was completed, believing the incident was based on staff assumptions. The facility also failed to investigate allegations involving Resident 103, who had Alzheimer’s disease and Parkinson’s disease. Staff reported that Resident 105 attempted to take Resident 103 into a shower room to perform sexual acts, and that a staff member intervened. The complainant later spoke with Resident 103, who stated that Resident 105 was “sick” and made bad comments. Other staff reported to human resources, the DNS, and the Administrator that Resident 105 attempted to take a resident into a shower room to unclothe the resident, and that Resident 105 attempted to video Resident 103, expressed a desire to kiss Resident 103, and get the resident into a shower room. The Social Service Director confirmed she reported these concerns to the Administrator, who stated he was aware of the incident but that no investigation was completed. A third failure to investigate involved Resident 108, who had Huntington’s disease and dementia. A staff member reported observing Resident 105 telling Resident 108 to take off their shirt and gesturing for them to do so, and stated they completed a written statement and gave it to the unit manager. Another CNA reported hearing that Resident 105 and other residents were laughing and encouraging Resident 108 to remove their top, and also reported observing Resident 105 rubbing other residents’ backs more physically than appropriate. Social services reported being told that Resident 108 was removing their top while Resident 105 was in the dining room with a phone, and that Resident 105 admitted to the behavior but described it as innocent. The Administrator stated he was aware of Resident 108 removing their shirt while Resident 105 was present, yet confirmed that no investigation was completed for this incident. These failures to investigate led surveyors to determine that the facility did not respond appropriately to alleged violations of sexual abuse for the three residents.
Removal Plan
- Residents 102, 103, and 108 received head-to-toe skin assessments completed by RCMs with no observed findings.
- Resident 105 was placed on one-to-one observations pending investigations.
- Staff 1 (Administrator) and Staff 2 (DNS) were re-educated on the facility's abuse policy, reporting, and thorough investigations.
- Social Services will interview all interviewable residents regarding abuse.
- Nurses will complete a head-to-toe assessment on all non-interviewable residents.
- All staff, including agency staff, will be re-educated on the facility's abuse policy and reporting.
Failure to Follow Care-Planned Hoyer Lift Transfer Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow a resident’s care plan interventions for transfers, resulting in a transfer being performed without required equipment and assistance. A resident admitted in February 2026 with multiple sclerosis had a 2/25/26 ADL care plan indicating the resident was dependent on two staff members for transfers and required use of a Hoyer (mechanical) lift. Despite this, on 2/28/26 a CNA (Staff 3) performed a stand-pivot transfer without the Hoyer lift and without a second staff member. The resident later reported that Staff 3 gave a “giant bear hug” and made several attempts to transfer the resident from chair to bed, after which the resident reported right flank pain and stated the transfer caused three broken ribs. An x-ray on 3/10/26 showed no rib fractures or dislocation, and the resident was assessed to have no visible injury. During interview, Staff 3 confirmed she had completed a stand-pivot transfer with the resident and acknowledged she had not read the resident’s care plan, and the Administrator confirmed that the resident had been care planned for a two-person Hoyer lift transfer at the time of the incident.
Failure to Provide Ordered Rehabilitative Services
Penalty
Summary
The facility failed to provide ordered rehabilitative services to a resident with multiple sclerosis. The resident was admitted in February 2026 with admission orders dated 2/24/26 for both physical therapy and occupational therapy. Review of the resident’s clinical record showed no documented evidence that any therapy services were provided as ordered. In an interview on 3/11/26 at 10:58 AM, the resident reported not having received any therapy since admission. During a separate interview on 3/11/26 at 10:40 AM, the Director of Rehabilitation confirmed that the resident had not received any therapy services from the date of admission through 3/11/26, despite the existing orders for physical and occupational therapy. This failure to implement the physician’s orders for rehabilitative services for this resident placed the resident at risk for a decline in range of motion.
Failure to Provide and Accurately Document Scheduled Bathing for a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a dependent resident received required assistance with activities of daily living (ADLs), specifically bathing, and inaccurate documentation that bathing had been provided. The resident, admitted in 10/2025 with dementia and stroke, had a 10/21/25 admission MDS indicating severe cognitive impairment and dependence on staff for showers. The facility’s 12/2025 CNA task report showed the resident was scheduled for bathing on day shift on Wednesdays and Sundays. On 12/24/25, the task report was blank for bathing, and on 12/28/25, the report documented that the resident received bathing and was dependent on staff for assistance. However, a 12/29/25 facility investigation determined the resident did not receive a bath on 12/28/25 and that it had been falsely documented that bathing occurred. A Facility Reported Incident form dated 12/31/25 further documented that on 12/28/25, a CNA (Staff 5) noted providing bathing to the resident but did not provide any type of bathing. Additional record review showed that the resident’s 3/2026 CNA task report contained no documentation that any type of bathing was provided on 3/11/26. Attempts to contact Staff 5 on 3/16/26 and 3/17/26 were unsuccessful. During interviews, another CNA (Staff 7) stated that on 12/28/25 she observed Staff 5 lay the resident down and, when she asked about bathing, Staff 5 said she would complete the resident’s bathing in the evening; Staff 7 stated she could not perform the resident’s bathing in the evening because she moved to a different hall on evening shift. Another CNA (Staff 21) stated that usually if bathing was not documented in the resident’s record, bathing did not occur. The Regional Nurse (Staff 31) stated that staff should provide scheduled bathing to residents.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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