Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Gateway Care And Retirement during CMS and state inspections, most recent first.
Surveyors identified multiple deficiencies in kitchen food storage and sanitation, including improper labeling and dating of food, failure to wear hairnets, inadequate hand hygiene, and improper storage of raw chicken above eggs. Staff interviews confirmed a lack of adherence to facility food safety policies and procedures.
A resident with depression did not receive individualized activities or one-to-one visits as outlined in their care plan and preferences. Despite documented interests in music, reading, gardening, and spiritual activities, the resident spent most of their time in bed without access to preferred materials or programming, and staff were unaware or had not facilitated these activities.
A resident with a high risk for elopement, due to a history of nontraumatic intracerebral hemorrhage and seizure disorder, exited the facility unsupervised on multiple occasions. The care plan required a Code Pink protocol, but staff failed to implement these interventions. A CNA was unaware of the resident's elopement risk and did not perform 30-minute checks, leading to the resident being found at a nearby hospital. The DNS and Clinical Management Specialist acknowledged the failure to prevent the elopement.
A resident with a history of manic episodes experienced abuse when a provider gripped their shirt, dragged them, and slammed them onto their bed, holding them down while yelling and taunting them. The incident was witnessed by staff who intervened, and the facility's investigation substantiated the abuse.
The facility failed to follow physician orders and assess medical conditions for three residents. One resident with multiple diagnoses did not receive prescribed medication despite significant weight gain. Another resident experienced significant weight loss without assessment or referral to the NAR team. A third resident had a notable weight gain without any assessment or justification.
A cognitively impaired resident left the facility without informing staff or signing out, remaining out for two days and requiring hospitalization. The resident's care plan lacked interventions for this behavior, and there were gaps in documentation. Staff interviews confirmed previous similar incidents and inadequate response on the date in question.
Deficient Food Storage and Sanitation Practices in Kitchen
Penalty
Summary
Surveyors observed multiple failures in food storage and sanitation practices within the facility's kitchen. A three-tiered cart was found sticky with an unknown substance and food debris, yet clean food storage containers were placed on it. Two dietary employees were seen preparing for lunch without wearing hair nets, and a spill of a white sticky substance with aluminum foil stuck to it was present in the reach-in freezer. Opened, undated, and unsealed bags of stuffing and Oreo pieces were found, and a bag of brown, decaying celery was stored in the refrigerator. Additionally, a food storage container of cream of mushroom soup was labeled without a date, and raw chicken breast was stored above pasteurized eggs, not on the bottom shelf as required. Staff were also observed not washing hands with soap and water before donning gloves after handling raw chicken, and an employee entered the kitchen from the outdoor dumpster area without washing hands or putting on a hairnet. Interviews with staff confirmed a lack of adherence to food safety protocols. The cook admitted there was no process for labeling opened foods and acknowledged improper storage of raw chicken. The dietary manager confirmed that employees were required to wear hairnets at all times, label and date all food items, and wash hands upon entering the kitchen and between tasks, but these practices were not being followed. The administrator stated an expectation for staff to follow food safety guidelines and facility policies, but the observed actions and staff statements indicated these standards were not maintained.
Failure to Provide Person-Centered Activities Program
Penalty
Summary
The facility failed to provide an ongoing, person-centered activities program for a resident with a diagnosis of depression who was admitted in November 2023. According to the resident's care plan and MDS, the resident enjoyed activities such as dancing, music, television (especially sports), reading, spiritual activities, word finds, crossword puzzles, gardening, and going outside for fresh air. Despite these documented preferences, activity task records showed that the resident did not participate in any in-room or out-of-room activities, nor did they receive one-to-one visits during the review period. Observations confirmed that the resident spent most of their time in bed, with no visible books, magazines, newspapers, plants, or flowers in the room, and the shared television was controlled by the roommate, limiting access to preferred programming. Interviews with staff revealed a lack of awareness and follow-through regarding the resident's activity preferences. Staff members were unsure about the resident's interests, had not recently provided books or music, and had not facilitated opportunities for the resident to go outside or receive religious visits, despite these being important to the resident. The activity director acknowledged not providing individualized activities or one-to-one visits and had not offered religious visits since shortly after admission. The director of nursing stated an expectation for individualized activity programming, but this was not reflected in the care provided.
Failure to Implement Elopement Prevention Measures
Penalty
Summary
The facility failed to implement care plan interventions to prevent the elopement of a resident who was identified as a high risk for elopement. The resident, admitted with a diagnosis of nontraumatic intracerebral hemorrhage and a seizure disorder, had a care plan dated 2/29/24 indicating a high risk for elopement with interventions to implement a Code Pink protocol. Despite this, the resident had multiple unwitnessed exits from the facility, as noted in a 4/23/24 progress note and a 2/2/25 incident report. On both occasions, the resident was found at a nearby hospital after wandering unsupervised from the facility. The facility's failure to implement the care plan interventions was further highlighted by staff interviews. On 2/6/25, a CNA indicated she was unaware of the resident's elopement risk and did not perform the required 30-minute checks, mistakenly believing the resident was independent. Additionally, the CNA did not report the resident's absence until the shift exchange. The DNS and Clinical Management Specialist confirmed the facility's failure to implement the necessary interventions to prevent the resident's elopement.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to ensure residents were free from abuse, as evidenced by an incident involving a resident with a history of manic episodes and no cognitive impairment. During a routine visit, a provider gripped the front of the resident's shirt, dragged them, and slammed them onto their bed, holding them down while yelling and taunting them. This altercation was witnessed by two staff members who intervened and stopped the incident. The resident reported feeling that their pride was affected but confirmed no physical harm occurred. Witness statements corroborated the resident's account, with the provider admitting to losing their temper and holding the resident down as an act of self-defense. The facility's investigation substantiated the abuse based on these statements. The incident highlights a failure in protecting residents from abuse, as the provider's actions were aggressive and unprofessional, leading to a physical confrontation that was witnessed and stopped by staff members.
Failure to Follow Physician Orders and Assess Medical Conditions
Penalty
Summary
The facility failed to ensure physician orders were followed and medical conditions were assessed for three residents. Resident 5, who was admitted with diagnoses including pneumonia, acute respiratory disease, acute heart failure, hypertension, and vascular disease, had a physician order for 40 mg of Furosemide to be given every 24 hours PRN for specific conditions such as edema, shortness of breath, or significant weight gain. Despite documented weight gains that met the criteria for administering the medication, the Furosemide was only given on two occasions, leading to a lack of adherence to the physician's orders. Staff 2 acknowledged the oversight but provided no additional information on why the orders were not followed consistently. Resident 1, admitted with diagnoses including pain and depression, experienced a significant weight loss from 242.9 lbs to 199 lbs over a few months. Despite this significant weight loss, there was no assessment, evaluation, or referral to the Nutrition At Risk (NAR) team. Staff 2 confirmed that the weight loss should have been assessed and followed up on but could not explain why it was not. Similarly, Resident 2, admitted with heart disease, experienced a weight gain of 14.8 lbs over 16 days. There was no assessment or justification for this weight gain, and Staff 2 acknowledged that the facility should have assessed the weight gain but did not provide further information on why it was not done.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure safety interventions were in place to prevent elopement for a resident who was cognitively impaired and had poor decision-making skills. The resident, who used a four-wheeled walker for ambulation, left the facility without informing staff or signing out. The resident was out of the facility for two days, during which time they went to the hospital and were later readmitted to the facility. There was no documentation in the resident's electronic health record or the facility's Resident Sign Out Log to indicate the resident had left the facility on the specified date. Staff interviews revealed that the resident had previously left the facility without informing staff and that the police had been called on a prior occasion. However, on the date in question, the night shift nurse was instructed to hold off on calling the police. The resident's care plan did not reflect any interventions related to their behavior of leaving the facility without informing staff. The facility's administrator acknowledged the gaps in documentation and the failure to update the care plan with the resident's behavior and the necessary education for the resident.
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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 Portland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Glisan Post Acute | 0.2 mi | ★★★★★ | 11 | 0 |
| Marquis Mill Park | 0.7 mi | ★★★★★ | 13 | 0 |
| Rose City Nursing And Rehabilitation | 0.9 mi | ★★★★★ | 1 | 0 |
| Portland Health And Rehabilitation | 1 mi | ★★★★★ | 21 | 0 |
| Menlo Park Post Acute | 1 mi | ★★★★★ | 15 | 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 July 2026) and official state health department websites.