Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Avamere Crestview Of Portland during CMS and state inspections, most recent first.
Medication carts contained expired and improperly labeled meds. A medication cart had expired fish oil and aspirin, a treatment cart had Humalog insulin without an open date plus lotions without expiration dates, and another cart had expired Nystatin powder. Staff, including a CMA, LPN, RN, and DNS, confirmed the missing dates and expired products during the survey observation and record review.
A resident with no cognitive impairment was given melatonin at bedtime, and staff left the medication at the bedside for later use without completing a self-administration assessment. The LPN care manager said she obtained the order to leave the medication at the bedside but did not complete the required assessment, and a CMA confirmed she left the medication when the resident was not ready to take it.
Failure to assess and document wheelchair seatbelt use: A resident with cerebral palsy, stroke, dementia, and muscle weakness was observed with the wheelchair seatbelt fastened whenever up in the wheelchair. Staff described the seatbelt as being used for security, to prevent sliding, and to keep the resident in the chair, but the record had no physician order, consent, safety device assessment, monitoring, or care plan for its use.
Failure to provide ADL assistance and grooming: Two residents who needed help with hygiene did not receive consistent showers or personal grooming. One resident with cognitive impairment and incontinence missed scheduled showers, had no documented make-up showers, and was observed wearing the same clothing with greasy, uncombed hair. Another resident with severe cognitive impairment and total-care needs was observed with excessive facial hair and matted, tangled hair, and staff acknowledged grooming care had not been consistently provided.
Incomplete person-centered activity planning affected two residents. One resident with stroke and dysphagia was cognitively intact, but the activity profile was incomplete, the care plan lacked individualized preferences, and the resident said activities were not offered and Bible Study was not communicated. Another resident with PTSD and severe cognitive impairment had activity preferences documented in the MDS and care plan, but observations and staff interviews showed the resident was often left with cartoons on TV and no reading materials, while staff gave inconsistent information about the resident’s interests.
Failure to Follow Fall Safety Care Plans: Staff did not consistently follow fall precautions for 3 residents with fall histories and high fall risk. One resident had repeated falls, a lumbar fracture, and required a grabber, low bed, and posted fall alerts, but the bed was often left high, the grabber was out of reach, and signs were missing. Two other residents also had care plans requiring low bed positioning, yet their beds were observed at waist height and staff showed inconsistent knowledge of the ordered fall interventions.
Failure to provide resident-specific trauma-informed care for a resident with PTSD. The resident had a military-related trauma history, severe cognitive impairment, anxiety, and nightmares, but the trauma care plan remained general and did not identify specific triggers such as loud noises, war or military discussions, the news, or military uniforms. Staff interviews showed mixed awareness of the resident’s trauma history and triggers, and the SSW Director did not obtain a fuller family history when the resident could not complete the trauma assessment.
Medication Error Rate Exceeded Due to Unprimed Insulin Pens. The facility had an 8% medication error rate, with 2 errors in 25 medication administration opportunities. An LPN administered insulin NPH and insulin aspart to a cognitively intact resident without priming the insulin pens, and the LPN stated they were not aware priming was required. The DNS later stated all nursing staff were expected to prime insulin pens before giving insulin.
Palatability and Presentation of Puree Meals: A resident with stroke and dysphagia on a puree diet reported meals were bland and unappetizing, and test trays showed multiple puree items lacked flavor, visual appeal, and identifiable characteristics. The ADM and Dietary Mgr acknowledged the puree meals did not consistently match the menu items and that meal presentation and flavor needed improvement.
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.
Medication carts contained expired and improperly labeled medications
Penalty
Summary
The facility failed to ensure medications were properly labeled and expired medications were removed from medication carts immediately for 3 of 5 sampled medication carts reviewed. The facility policy dated 1/2025 instructed staff to immediately remove outdated medications from stock and to note the date insulin vials and pens were first used. During observation on 2/11/26, the 30/40 hall medication cart contained a bottle of Fish oil 1000 mg with an expiration date of 12/2025 and a bottle of Aspirin 325 mg with an expiration date of 10/2025. Staff 21, a CMA, confirmed the expired dates and stated the medications should have been removed and destroyed. The treatment cart number two contained a vial of Humalog insulin without an open date written on it, and the manufacturer's instructions indicated it should not be used past 28 days from the open date. The same cart also contained tubs of Eucerin lotion and Cetaphil lotion with no expiration dates on the containers. Staff 22, an LPN, confirmed the missing open date on the insulin vial and the missing expiration dates on the lotions. The station three cart contained a box of Nystatin powder with an expiration date of 12/2024, and Staff 14, an RN, confirmed the expiration date and removed the medication from the cart. On 2/12/26, Staff 2, the DNS, confirmed open dates should have been written on insulin vials and that medication carts should be checked regularly before administering medications to ensure powders and other medications were not expired.
Failure to Assess Self-Administration Before Leaving Medication at Bedside
Penalty
Summary
The facility failed to ensure a resident was assessed for safe self-administration of medications before melatonin was left at the bedside for the resident to take later. The facility’s policy stated residents may self-administer medications only when the interdisciplinary team determines it is clinically appropriate and safe, and that the team assesses each resident’s cognitive and physical abilities to determine whether self-administration is safe. Resident 3 was admitted with diagnoses including a fracture of the fourth lumbar vertebra, and the 12/23/25 Significant Change MDS indicated no cognitive impairment. An 8/11/25 physician order directed that melatonin at bedtime could be left at the bedside for Resident 3 to take when ready, and the 1/2026 and 2/2026 TAR showed the resident received melatonin each evening. The clinical record contained no evidence that a self-administration of medication assessment was completed. Resident 3 stated the medication was sometimes brought when he/she was not ready to take it and staff left it for later. Staff stated medications could be left at the bedside if the resident was assessed as safe, and the LPN care manager acknowledged she obtained the order to leave the medication at the bedside but did not complete the self-administration assessment, stating it did not trigger in her mind.
Failure to Assess and Document Wheelchair Seatbelt Use
Penalty
Summary
The facility failed to obtain consent, assess, monitor, and reevaluate a resident for the use of a wheelchair seatbelt for 1 of 1 sampled resident reviewed for restraints. Resident 60 was admitted with diagnoses including cerebral palsy, stroke, dementia, and muscle weakness. The resident's quarterly MDS dated 1/17/26 indicated use of a wheelchair and no restraints were used. Review of the clinical record found no documentation that the resident was assessed, care planned, or monitored for the wheelchair seatbelt, and there was no evidence of a physician order. The risks and benefits of the wheelchair seatbelt had not been reviewed with the resident or resident representative since 9/3/24. Observations from 2/9/26 through 2/12/26 showed that whenever Resident 60 was in the wheelchair, the seatbelt was fastened. The resident stated the seatbelt was always used to prevent falling from the wheelchair. A CNA stated the resident used the seatbelt to feel more secure, and another CNA stated it was supposed to be fastened when the resident was up in the wheelchair and used to help prevent sliding down. An RN stated the seatbelt was used because the resident's oxygen fluctuated and to keep the resident in the wheelchair. The RNCM confirmed the resident used the wheelchair seatbelt and verified there was no physician order, safety device assessment, consent, monitoring, or care planning completed for its use.
Failure to Provide ADL Assistance and Grooming
Penalty
Summary
The facility failed to ensure dependent residents received showers and needed grooming and hygiene assistance. The facility’s Activities of Daily Living policy stated residents unable to perform ADLs independently would receive services necessary to maintain grooming, personal hygiene, and oral hygiene. Resident 68, admitted with spinal stenosis and diabetes, had mixed bowel and bladder incontinence, mild to moderate cognitive impairment, and required partial to moderate assistance with showering. The resident was scheduled for showers twice weekly, but shower task logs showed missed showers on 1/15/26, 2/8/26, and 2/12/26. Progress notes did not show that missed showers were made up or that additional shower opportunities were offered when showers were refused or not provided. During observations, Resident 68 wore the same gray sweatpants each day, wore the same dirty white T-shirt until 2/12/26, and had greasy, uncombed hair. The resident stated showers were missed because staff did not return or forgot. Resident 31, admitted with congestive heart failure and chronic respiratory failure with hypoxia, had severe cognitive impairment and required substantial assistance with personal hygiene. The care plan identified one-person assistance for combing hair and shaving. During observation, Resident 31 had excessive visible facial hair and hair that appeared matted, tangled, and secured in a knotted ponytail. The resident stated he/she could not shave or comb the hair independently because he/she could not lift the shoulders. Staff acknowledged the facial hair and large knot in the hair, and one LPN stated the resident was not care planned for grooming related to facial hair or interventions to address the knot. The DNS and other staff acknowledged the resident had not consistently received grooming and hygiene care in accordance with the resident’s needs.
Incomplete Person-Centered Activity Planning
Penalty
Summary
The facility failed to provide an ongoing person-centered activities program for 2 residents reviewed for activities. The facility’s Activity Program stated that activities were to support resident well-being, encourage independence and community interaction, and be based on each resident’s comprehensive resident-centered assessment, preferences, needs, and interests. Survey findings showed that the activity assessments and care plans for the 2 residents did not consistently reflect their individual preferences, routines, or needs, and staff interviews confirmed that activity information was not adequately identified or communicated. One resident was admitted with stroke and dysphagia and was cognitively intact on the admission MDS. The MDS identified several important preferences, including reading books, newspapers, and magazines, being around animals, going outside for fresh air, and participating in religious services. However, the Activity Profile was incomplete, lacked documentation of preferences and interests, and the activity care plan only noted self-directed activities and interests in news and sports. Activity task records showed limited participation, observations showed the resident spending most of the time in the room with no reading materials visible, and the resident stated activities were not offered and that the Bible Study was not communicated. Multiple CNAs stated they were unaware of the resident’s preferences, and the DNS confirmed activities had not been individualized. The second resident had PTSD and severe cognitive impairment. The resident’s MDS identified preferred activities such as keeping up with the news and having reading materials available, and the activity care plan listed television, music, bingo, current events, and self-directed materials. However, observations showed the resident in the room or dining room with the television playing cartoons and no reading materials available. The resident and family member stated the resident preferred other programming and reading materials, while several staff members gave differing accounts of the resident’s preferences and whether reading materials were offered. The Administrator acknowledged the activity care plan needed revision because the resident was no longer able to self-initiate activities, cartoons were not the resident’s preference, and newspapers should be distributed to residents with an expressed interest.
Failure to Follow Fall Safety Care Plans
Penalty
Summary
The facility failed to ensure staff followed care plans related to fall safety for 3 residents who were reviewed for falls. The report states the facility’s Falls and Fall Risk Managing policy required staff to identify interventions based on each resident’s specific fall risks and to implement a resident-centered fall prevention plan for residents at risk for falls or with a history of falls. Resident 3 was admitted with a diagnosis including a fracture of the fourth lumbar vertebra and had repeated falls, with multiple Morse Fall Scale assessments indicating high fall risk. The resident’s fall care plan identified risks including weakness, impulsivity, mixed incontinence, self-transferring, need for assistance, and a history of falls, with interventions including keeping the bed in low position except during care, posting a call, don’t fall sign, ensuring the grabber was within reach, and use of a falling star program. Observations showed the bed repeatedly left in a high position, the grabber placed out of reach on a dresser across the room, and the absence of the call, don’t fall sign and yellow falling star sign during multiple observations. Staff also observed Resident 3 in the dining room without the grabber available, and one CNA entered the room with the bed still high and did not lower it. Resident 3 stated staff often left the bed high after care, did not know where the grabber was, and reported the falling star sign had been removed after the room door was kept closed. Resident 6 had a history of repeated falls and was assessed as high risk for falls. The resident’s care plan directed that the bed be kept in a low position at all times except during care. Observations showed Resident 6 in bed with the bed positioned between knee-to-waist height and later at waist height. Staff present in the room did not encourage the resident to lower the bed, and one CNA lowered only the head of bed at the resident’s request before leaving the room. Staff interviews showed inconsistent knowledge of the resident’s fall interventions, with some staff stating the bed should always be in the lowest position and another stating he preferred to keep the bed at waist height. Resident 35 had a history of falls, was assessed as high risk for falls, and was severely cognitively impaired. The resident’s care plan also required the bed to be kept in a low position when not receiving care. Observations showed the bed repeatedly positioned at waist height while the resident was in bed. Staff interviews again showed inconsistent understanding of the resident’s fall precautions, with some staff stating the bed should be low and others stating they did not know the resident’s fall risk status or the required bed height. The report documents that staff did not consistently follow the residents’ fall-related care plan interventions.
Failure to Provide Resident-Specific Trauma-Informed Care
Penalty
Summary
The facility failed to ensure that a resident with post-traumatic stress disorder received trauma-informed care that reflected the resident’s specific trauma history and triggers. The facility’s policy required residents to be screened for traumatic events, assessed further as needed, and have individualized care plans developed to address past trauma, including triggers and cultural or language needs. Resident 35 was admitted with a diagnosis of PTSD and had an initial trauma-informed care evaluation in which the resident did not want to complete the assessment and/or stated no trauma had been experienced. A trauma care plan was created with general interventions such as announcing presence, avoiding startling the resident, maintaining distance if triggered, and stopping care if the resident was uncomfortable. The resident’s record also showed a military background and later documentation that the resident enjoyed patriotic music, watched the news, and served in the military. A quarterly MDS identified severe cognitive impairment and an active PTSD diagnosis, and a social service review noted episodes of anxiety often treated with psychotropic medications. During observation, the resident was asleep in bed and yelled out multiple times after a knock on the door without awakening. The resident’s family member stated the PTSD was related to military service, that the resident had nightmares for decades, and that loud noises, the news, discussion of war or the military, and seeing a military uniform were triggers. Staff interviews showed inconsistent awareness of the resident’s trauma history and triggers. Several CNAs and an RN stated they were unsure of the resident’s specific triggers and would look to the care plan for guidance, while one CNA stated that military conversations and war-related topics definitely caused anxiety and scared the resident. The Social Services Director stated she completed the initial trauma evaluation but did not reach out to the family for a fuller understanding of the resident’s trauma or triggers and was unaware of the nightmares and possible triggers such as military discussions or watching the news. The Administrator stated she expected residents with PTSD or trauma history to have care plans with resident-specific triggers and interventions, and acknowledged the resident’s trauma care plan was general and did not include specific triggers, interventions, or activities to avoid.
Medication Error Rate Exceeded Due to Unprimed Insulin Pens
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent, with 2 errors identified out of 25 medication administration opportunities for an 8% error rate. Surveyors observed and reviewed records showing that Resident 9, who was admitted in 1/2026 with diagnoses including aftercare following a liver transplant and was cognitively intact on the admission MDS, had physician orders in 2/2026 for insulin NPH 21 units in the morning, insulin aspart 15 units before meals, and insulin aspart 4 units with meals per sliding scale. On 2/10/26 at 7:32 AM, an LPN administered insulin NPH and insulin aspart to Resident 9 without priming the insulin pens before administration. The LPN acknowledged not priming the pens and stated they were not aware priming was required. The DNS was later notified that the insulin pens had not been primed and stated they expected all nursing staff to prime insulin pens prior to administering insulin.
Palatability and Presentation of Puree Meals
Penalty
Summary
The facility failed to provide appetizing and palatable food for 1 of 2 sampled residents reviewed for food service. Resident 43 was admitted with diagnoses including stroke and dysphagia and was on a puree diet. The resident stated the puree meals were bland, that everything was yuck, and that the potatoes tasted like powder. A review of the lunch menu showed the facility was to serve rosemary herbed baked chicken, roasted red potatoes, cauliflower au gratin, a dinner roll with margarine, pumpkin cake with whipped topping, and a beverage, and kitchen meal service was observed serving those items. During test tray sampling of puree diets, the rosemary herbed chicken was described as bland and lacking visual appeal, the cauliflower au gratin was bland and lacked identifiable characteristics, the dinner roll was doughy and lacked visual appeal, and the pumpkin cake with whipped topping was bland and lacked visual appeal. A second puree test tray showed braised roast pork was bland and not identifiable by taste, garlic green beans were bland, the dinner roll was doughy and lacked visual appeal, and the sherbet cup was bland with no flavor. The Administrator stated the braised roast pork did not taste consistent with the menu item and the green beans were not identifiable by taste, and the Dietary Manager acknowledged concerns with the appearance of puree diets and stated the kitchen needed to improve puree meal quality, including flavor and presentation.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 549 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Portland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marquis Vermont Hills | 1.5 mi | ★★★★★ | 2 | 0 |
| Robison Jewish Health Center | 1.6 mi | ★★★★★ | 23 | 0 |
| West Hills Health & Rehabilitation | 1.6 mi | ★★★★★ | 0 | 0 |
| Marquis Autumn Hills Memory Care | 1.6 mi | ★★★★★ | 7 | 0 |
| Mirabella Portland | 2.4 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.