Above average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Holladay Park Plaza during CMS and state inspections, most recent first.
Failure to follow physician orders affected two residents. One resident with osteoporosis and a fractured femur missed ordered calcium supplements because the meds were not administered and the pharmacy and MD were not notified. Another resident with Parkinson's disease had an order and care plan for bilateral bed rails to support bed mobility, but the bed was observed without rails and staff confirmed the rails were not implemented.
Unsecured Medications Left in Resident Room: A resident’s room contained visible, unattended prescription pill bottles and a pill organizer belonging to a visitor, with the items left on a window ledge in a high-traffic area. The resident was alert and oriented and needed 1-person assist for mobility, while staff confirmed the meds were unsecured and should not have been in the room unless locked up.
The facility failed to provide a resident with a written notice of the bed hold policy at the time of transfer to the hospital. The resident, admitted with congestive heart failure, was transferred due to a change in condition, and no record of the bed hold policy being provided was found. This was confirmed by the DNS.
The facility failed to follow physician orders for a resident with heart disease and edema, missing multiple days of required daily weights. The resident was observed with a swollen right leg and reported significant pain. Staff confirmed the physician's order for daily weights was missed.
Failure to Follow Medication Orders and Implement Ordered Bed Rails
Penalty
Summary
The facility failed to follow physician orders for Resident 3, who was admitted with diagnoses including osteoporosis and a fractured left femur. An 8/7/25 order prescribed calcium citrate plus once daily, but the MAR showed the medication was not administered on 8/7/25 through 8/11/25, and it was discontinued on 8/11/25. A subsequent 8/12/25 order prescribed calcium citrate with vitamin D once daily, but the MAR showed missed doses from 8/12/25 through 8/24/25. Staff 4 confirmed all doses of calcium citrate plus were missed and 13 doses of calcium citrate with vitamin D were not administered, and stated the pharmacy was not contacted and the physician was not notified regarding the missed doses. The facility also failed to implement ordered bed rails for Resident 9, who was admitted with diagnoses including Parkinson's disease, syncope, and collapse. A physician order dated 8/12/25 directed that bedside rails be used to support bed mobility, and a bed rail assessment approved use of one-half side rails on both sides of the bed. The admission MDS indicated the resident was cognitively intact. However, the resident's bed was observed without bed rails on 9/2/25 and 9/3/25, and the resident stated a preference for bed rails to assist with mobility due to Parkinson's disease. Staff 4 confirmed the resident's fall prevention interventions included bilateral bed rails and acknowledged they were not in place, and Staff 2 confirmed the bilateral bed rails were not implemented.
Unsecured Medications Left Visible in Resident Room
Penalty
Summary
The facility failed to ensure a resident environment was free from accident hazards when unsecured medications were left in Resident 49’s room. Resident 49 was admitted with diagnoses including depression, and the 8/25/25 Cognitive and Communication Care Plan indicated the resident was alert and oriented and required one person staff assistance for mobility. During observations from 9/2/25 through 9/3/25, three brown prescription pill bottles labeled with Witness 1’s name were visible on the window ledge in Resident 49’s room, along with a blue daily pill organizer containing unidentified medications. The medications were visible from the hallway, and on multiple observations neither Resident 49 nor Witness 1 was in the room while the medications remained unattended. The room was in a high traffic area with the door frequently open, and nursing staff, therapy staff, kitchen personnel, administrative staff, residents, visitors, and outside vendors such as laboratory personnel were observed passing by or entering the room. Witness 1 stated the medications belonged to him, that he left them in the room when he left the facility each day, and that he was not offered a lock box or asked to remove them. Staff 8 stated the pill bottles and pill organizer had been on the window ledge since the resident was admitted. Staff 4 confirmed the medications were unsecured in the room and stated they should not have been there unless there was a physician order and they were locked up. Staff 1 verified there should be no unsecured medications at any resident’s bedside.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide residents with a written notice of the facility's bed hold policy at the time of transfer to the hospital. This deficiency was identified for one resident who was admitted to the facility in March 2024 with diagnoses including congestive heart failure. On March 23, 2024, the resident experienced a change in condition requiring increased medical attention and was transferred to a hospital. A review of the resident's records revealed no indication that a physical copy of the facility's bed hold policy was provided at the time of transfer. This was confirmed by the Director of Nursing Services on June 13, 2024.
Failure to Follow Physician Orders for Daily Weights
Penalty
Summary
The facility failed to follow physician orders for a resident with heart disease and edema. The physician's order from 5/21/24 directed the resident to be weighed daily before breakfast for four weeks. However, a review of the resident's weight records for May and June 2024 revealed multiple days when the resident was not weighed. On 6/10/24, the resident was observed with a swollen right leg and reported experiencing chronic edema and significant pain. Staff confirmed that the physician's order for daily weights was missed.
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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) |
|---|---|---|---|---|
| Laurelhurst Post Acute & Rehabilitation | 1.3 mi | ★★★★★ | 3 | 0 |
| Providence Child Center | 1.9 mi | ★★★★★ | 2 | 0 |
| Belmont Care And Rehabilitation | 2.2 mi | ★★★★★ | 0 | 0 |
| Fernhill Rehabilitation And Care | 2.4 mi | ★★★★★ | 0 | 0 |
| Porthaven Post Acute | 2.5 mi | ★★★★★ | 9 | 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.