Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Beaverton Post Acute Care Of Cascadia during CMS and state inspections, most recent first.
Failure to follow a resident’s care plan for transport and mobility led to a fall during a dental appointment. The resident had stroke, dementia, and severe cognitive impairment, and the care plan required one-person assist in a wheelchair and use of a tilt-back wheelchair or stretcher for all transportation. Instead, the resident was taken to the appointment in a standard wheelchair, slid out onto the floor, and was sent to the ER; the RNCM confirmed the appropriate mobility device and transport services were not arranged.
Medication orders were entered and transcribed incorrectly for two residents. One resident with osteomyelitis received extra doses of ferrous sulfate and vitamin C because the EMR orders were entered incorrectly and not verified, while another resident with HF received losartan and spironolactone after admission even though the signed discharge orders had discontinued both medications.
A resident with sick sinus syndrome and acute DVT received Warfarin and Pradaxa outside the physician orders. The MAR showed Pradaxa was given before the scheduled start date and Warfarin was also administered, while PT/INR values rose to 7.2. Staff later stated the resident received two anticoagulants by mistake and that the new order was transcribed incorrectly.
A resident requiring a colostomy bag was left without one for about a day after the facility's vendor discontinued supply orders due to Medicaid funding changes. Staff covered the resident's stoma with a brief and pads instead, resulting in the resident missing activities that day.
During a review of medication storage, surveyors found two open, undated vials of tuberculin and two open, undated insulin pens in a medication room refrigerator. The DON confirmed these items were not dated and should have been discarded within 30 days of opening, as required by facility policy and state guidelines.
A resident with right-sided weakness following a cerebral infarction did not receive a needed AFO in a timely manner due to incomplete referral documentation and delayed follow-up by staff. As a result, the resident was unable to begin an ambulation restorative program and experienced decreased ROM, participating only in group therapy using a wheelchair.
A resident with hearing loss did not receive a timely referral to speech therapy despite an audiologic recommendation for aural rehabilitation. The resident, unable to hear with hearing aids, requested written communication, and staff interviews confirmed that the referral process was delayed and not in accordance with expected protocols.
A resident with PTSD did not have a trauma-informed care plan developed, and staff failed to identify or address trauma triggers. An LPN engaged in physical contact that the resident reported as triggering their PTSD, despite being aware of the diagnosis. Facility leadership confirmed that no interventions were implemented to address the resident's trauma history or triggers.
Failure to Follow Care Plan for Wheelchair Transportation
Penalty
Summary
The facility failed to follow a resident’s plan of care to prevent a fall for one resident reviewed for accidents. The resident was admitted with diagnoses including stroke and dementia, and the quarterly MDS indicated severe cognitive impairment. The care plan dated 3/31/26 stated the resident required one-person participation for mobility while in a wheelchair and was to use a tilt-back wheelchair or stretcher for all transportation. During a dental appointment, the resident slipped out of the wheelchair and onto the ground. A post-fall note stated the resident was taken to the emergency room and no injury was found. The dental provider stated the resident struggled to stay upright in the wheelchair during the appointment and eventually slid out onto the floor, and staff at the dental clinic could not safely assist the resident back into the chair, so emergency services were called. Facility staff stated residents going out for appointments were informed by nursing staff or care plans about needed mobility devices, but the RNCM confirmed the resident did not have the appropriate mobility device or transportation services set up for the dental appointment.
Medication Orders Entered and Transcribed Incorrectly
Penalty
Summary
The facility failed to ensure that residents received medications only as ordered by a physician for 2 of 3 sampled residents reviewed for medication errors. One resident, admitted in 2022 with osteomyelitis, had physician orders for ferrous sulfate 65 mg and vitamin C 500 mg only on Monday, Wednesday, and Friday, but the June 2026 MAR showed both medications were administered on Thursday. Staff stated the orders had been entered incorrectly into the electronic medical record, that the next shift nurse was supposed to verify the entries, and that the resident received one extra dose of each medication because of the error. A second resident, admitted with heart failure, had a discharge medication list that included losartan and spironolactone, but the signed discharge order indicated both medications were to be discontinued before admission to the facility. The April 2026 MAR showed the resident received one dose of each medication after admission. Staff stated the medication list uploaded into the chart came from the discharge medication list rather than the signed discharge orders, and another staff member later identified the discrepancy and confirmed the medications were given in error.
Medication Error With Concurrent Anticoagulant Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors involving anticoagulants. The resident was admitted with diagnoses including sick sinus syndrome requiring pacemaker insertion and acute deep vein thrombosis to both legs. Admission orders included Warfarin 3.75 mg every Thursday and Saturday and 2.5 mg every Friday until 4/21/26, with Dabigatran Etexilate Mesylate (Pradaxa) 150 mg twice daily to begin on 4/22/26. The MAR showed the resident received Warfarin on 4/10/26 and 4/12/26, and also received Pradaxa on 4/10/26, 4/11/26, 4/12/26, 4/13/26, and 4/14/26 even though the order was not to start until 4/22/26. On 4/11/26 Warfarin was held because the resident's PT/INR was 4.2, and the provider ordered a re-check. Progress notes show the PT/INR increased to 6.7 on 4/13/26 and 7.2 on 4/14/26. Staff later stated the resident received two anticoagulants by mistake, that the Pradaxa start date was missed, and that the new order was transcribed incorrectly as starting on 4/10/26 instead of 4/22/26.
Failure to Provide Timely Colostomy Supplies
Penalty
Summary
The facility failed to provide colostomy care according to professional standards for one resident who required such services. The resident, admitted with diagnoses including renal failure, had a care plan and physician orders indicating the use of a colostomy bag. On one occasion, the resident reported not having a colostomy bag for about a day, during which staff covered the stoma with a brief and other pads instead. This situation arose after the facility's vendor discontinued colostomy bag orders due to changes in Medicaid funding, and supplies were not immediately available. Staff confirmed the resident's account, noting that the resident was unable to attend activities that day due to the lack of a colostomy bag.
Undated and Expired Biologicals Found in Medication Storage
Penalty
Summary
Surveyors observed that the facility failed to ensure proper medication storage by allowing expired biologicals to remain in use. Specifically, during a review of one of three medication rooms, two open and undated vials of tuberculin and two open and undated insulin pens were found inside a refrigerator in the north hall medication storage room. According to the Oregon Health Authority and the facility's own medication storage policy, vials in use for more than 30 days should be discarded, and all drug containers must be properly labeled. The Director of Nursing confirmed that the vials and insulin pens were undated and acknowledged that staff are expected to discard such items within 30 days of opening.
Failure to Provide Timely Equipment for ROM Maintenance
Penalty
Summary
A deficiency occurred when the facility failed to provide necessary equipment to maintain range of motion (ROM) for a resident with limited mobility. The resident, who had a history of cerebral infarction resulting in right-sided weakness and was non-ambulatory, was assessed as needing an Ankle Foot Orthosis (AFO) to participate in an ambulation restorative program. Although an AFO was ordered in January, the referral lacked a provider signature and supporting documentation, leading to delays in processing. The resident was observed without the AFO several months later and reported decreased ROM after physical therapy services ended. Staff interviews confirmed that the resident was unable to ambulate without the AFO and only participated in group therapy using a wheelchair while waiting for the device. Further review revealed that the prosthetics and orthotics clinic denied the initial referral due to incomplete documentation, and additional paperwork was required. Staff acknowledged that the referral process and follow-up with outpatient providers were not conducted in a timely manner, resulting in a significant delay in the delivery of the AFO. This delay prevented the resident from starting the prescribed ambulation restorative program and maintaining or improving ROM as care planned.
Delay in Speech Therapy Referral for Resident with Hearing Loss
Penalty
Summary
The facility failed to provide timely speech therapy services for a resident with hearing loss who was admitted in 2024. An audiologic report from April 2025 recommended the resident begin an aural rehabilitation program and obtain a referral to speech pathology. Despite this, a speech evaluation and treatment order was not entered until August 2025, and there was no evidence in the medical record that the resident was seen by a speech pathologist. During this period, the resident reported being unable to hear with hearing aids and requested written communication. Staff interviews revealed that the Director of Rehab was unaware of the resident's earlier ear clinic visit and expected a referral to be made promptly after that appointment, but this did not occur. Staff also acknowledged that the referral to speech therapy was not entered in a timely manner, as expected protocol was to request an after-visit summary following outpatient appointments.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident with a diagnosis of PTSD. Upon admission, the resident was cognitively intact and able to communicate effectively. The facility's policy required staff to identify and minimize trauma triggers, but the resident's trauma history was not addressed in the care plan, and there was no evidence that family members were interviewed to identify potential triggers. The resident declined to complete the trauma assessment, but there was no further follow-up or individualized care planning related to trauma history or triggers. An incident occurred in which an LPN smelled the resident's hair, pushed the resident's wheelchair into their room, and hugged and rubbed the resident's arms, actions that the resident reported as triggering their PTSD. The LPN was aware of the resident's PTSD diagnosis from both the medical record and conversations with the resident. Despite this, no interventions or care plan elements were implemented to address the resident's trauma triggers. Facility leadership acknowledged that nothing had been implemented regarding the resident's trauma history or triggers.
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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.
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Nursing homes near Beaverton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maryville | 1.6 mi | ★★★★★ | 8 | 0 |
| Marquis Vermont Hills | 2.9 mi | ★★★★★ | 2 | 0 |
| West Hills Health & Rehabilitation | 3 mi | ★★★★★ | 0 | 0 |
| Robison Jewish Health Center | 3 mi | ★★★★★ | 1 | 0 |
| Marquis Autumn Hills Memory Care | 3 mi | ★★★★★ | 7 | 0 |
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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 October 2026) and official state health department websites.