Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
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 Laurelhurst Post Acute & Rehabilitation during CMS and state inspections, most recent first.
A facility failed to maintain room sink counters and an ICF wheelchair scale in safe condition. Two room sink counters had missing, rough laminate, and staff did not notice the damage; the Maintenance Director said the edges needed to be smoothed to prevent potential skin injury. A resident with a stroke history reported the ICF scale support column was loose and made the resident feel off balanced, and staff observed the column moving when touched.
Failure to monitor medication refrigerator temperatures on multiple floors was identified during review of temperature logs. Day shift and night/evening shift entries were missing across the second, third, and fourth floor medication refrigerators, even though vaccines were present in the refrigerators and the guidance in the record stated CDC recommends twice daily temps when vaccines are present. Staff confirmed nurses were responsible for documenting the temperatures and that the logs were expected to be complete and accurate.
Unlabeled and Undated Food in Resident Refrigerators: Food items in multiple resident refrigerators were found unlabeled and undated, including hot dogs, pizza snacks, potato salad, lean cuisines, dumplings, hot pockets, ice cream, yogurt, and an opened energy drink. A CNA, dietary aide, cook, and DNS all confirmed that resident food was expected to be labeled and dated, but staff were unsure of or inconsistent in their handling of refrigerator and freezer items.
A resident admitted after knee replacement surgery reported significant knee pain on arrival, but the ordered oxycodone was not available and pain medication was not given until the next day. A friend, the resident, a CNA, the pharmacist, and RNs confirmed the resident remained in pain, only one tablet was available instead of the full ordered dose, the resident declined the partial dose, and the nurse did not document the refusal, notify the MD, or assess the pain at admission.
A resident admitted with a pelvic fx had an unwitnessed fall and low O2 sat, prompting the MD to order a stat chest x-ray. The record did not show the x-ray was obtained, and staff interviews indicated stat imaging should have been completed the same day or within 4 to 6 hours, with the MD notified if it could not be done.
Delayed Resolution of Resident Grievances: A cognitively intact resident with cancer reported multiple grievances involving staffing, food services, another resident’s behaviors, and access to an ice machine. The follow-ups and written resolutions were not completed in a timely manner, and the DON/Administrator acknowledged that the resident did not receive resolutions within the expected timeframe.
The facility failed to follow and clarify physician orders for residents with dialysis needs, medication administration issues, and possible UTI symptoms. One resident with asthma, diabetes, edema, and later heart failure had a chest x-ray order that was not completed, another resident on dialysis had multiple meds held without documented orders to do so, and a third resident reported burning with urination but was not documented as being reported to the physician or monitored for a possible UTI; the resident was later hospitalized and diagnosed with a UTI.
A resident with ESRD had care plans for PD and a PD catheter, but no care plan for a chest dialysis port. The resident stated staff were not checking the chest port, and the record showed no monitoring orders or documentation. An RN said she checked the port on dialysis days without an order, while the RNCM and DNS acknowledged the port was not ordered or care planned for monitoring, despite staff expectations to check it every shift and around dialysis.
A resident with stroke-related left-sided paralysis and worsening cognitive impairment was placed on bilateral one-quarter bedrails, but the record lacked a clear assessment and rationale for the rail placement. Staff observed the rails positioned in the middle of the bed, with the resident’s leg over the rail at times, and staff reported the resident moved frequently in bed, hallucinated, and sometimes attempted to get up without assistance. The resident stated the rails hurt the knees and were often hit.
A resident with Celiac disease and a documented gluten allergy was repeatedly served meals inconsistent with a required gluten-free diet, despite staff being notified and the resident reporting distress over the issue. The RN stated dietary staff had not received the dietary slip and that the meal ticket initially did not show the gluten-free diet, while surveyors later observed a test tray that did not match the posted menu; the Dietary Mgr confirmed the menu was not followed.
Food was not palatable or served at an appetizing temperature for two residents. One cognitively intact resident and another resident admitted after knee replacement surgery both reported poor taste, and resident council minutes showed concerns about bland, unappetizing food. Surveyor-observed trays included a tough quesadilla with unmelted cheese, cold broccoli, and bland beef stroganoff, which the Dietary Mgr confirmed was cold and not palatable.
Staff failed to follow EBP for two residents with tube feeding and wounds. A CNA provided personal hygiene and bathing to one resident without proper gown and glove use, and staff later confirmed a cloth gown was not appropriate for EBP. For another resident with chronic wounds and MDRO, staff were observed entering the room without PPE, the EBP sign had been removed, and an RN performed wound care without hand hygiene and without a gown, despite active EBP orders.
Call Light Not Kept Within Reach: A resident admitted with a stroke diagnosis and identified as at risk for falls did not have the call light within reach during multiple observations. The call light was found out of reach and later under the bed, and an LPN stated it should be secured to the resident's sheets or gown so it could be reached. The DNS stated residents were to have their call lights within reach.
Several residents with conditions such as dysphagia, malnutrition, and failure to thrive did not receive their prescribed Medpass 2.0 nutritional supplements on multiple days. This occurred because the Dietary Manager faced delays in administrative approval for orders and was restricted in the amount that could be purchased, resulting in insufficient supply. Nursing staff and the DNS confirmed the supplement was frequently unavailable, and residents did not receive it as ordered.
A resident who required two-person assistance for transfers and was incontinent was not assisted to bed or provided incontinence care at her preferred time due to a staffing shortage, resulting in prolonged discomfort and soiled clothing. Staff confirmed that only one CNA was available for several hours, leading to a significant delay in meeting the resident's needs.
A resident with a recent fracture was discharged home without a completed home health referral or necessary caregiver, PT, and OT support services, despite prior care planning and physician recommendations. The resident and family had to arrange for care independently after discharge, and facility leadership acknowledged the lapse.
The facility failed to dispose of expired medications in several storage areas, including medication rooms and carts. Expired items such as nicotine patches, saline spray, and vitamin tablets were found, and staff admitted to not knowing the medication storage policy. The policy requires expired medications to be destroyed, but it did not specifically address vials, contributing to the oversight.
The facility failed to properly label and store food items in the kitchen and dining room refrigerator units and freezers, risking foodborne illness for residents. Unlabeled and undated food items, including filets, patties, and croutons, were found in the main kitchen. Expired and unlabeled items were also found in the second floor ICF unit freezer and on the third and fourth floors. Staff acknowledged these issues and stated that dietary staff were responsible for monitoring and discarding expired products.
A resident was discharged with instructions to take home all their medications, including 112 Oxycodone tablets. However, 56 tablets were missing upon arrival home. Despite the resident's report, the issue was not escalated, and facility records showed discrepancies, with some tablets being destroyed by staff. Key staff were unaware of the issue until months later.
A resident was discharged with missing Oxycodone tablets, which were not reported to management or the State Agency by the LPN or CMA who were informed. The DNS was unaware of the incident until months later, highlighting a failure in the facility's reporting procedures.
Two residents were not assessed for safe self-administration of medications, leading to potential risks. One resident, with kidney failure, had topical medications at bedside without assessment, while another, with dementia and diabetes, used cough drops frequently without safety evaluation. Staff removed the items upon discovery, confirming the lack of prior assessment.
A resident with hemiparesis, hemiplegia, and aphasia was not provided with necessary transfer assistance, despite being dependent on staff for transfers. The resident remained in bed over several days, although their care plan required the use of a mechanical lift and a tilt-in-space wheelchair. Staff interviews revealed confusion about who was responsible for transfers, with some believing only therapy staff could perform them, while the Director of Rehabilitation confirmed no such restriction existed.
Two residents in an LTC facility were not provided with activities tailored to their interests, leading to isolation and lack of engagement. One resident, with colon cancer and adjustment disorder, preferred music and reading but was not offered these activities. Another resident, with hemiparesis and aphasia, enjoyed being outside and listening to music but was not given these opportunities. Staff were unaware of the residents' preferences, and the facility's activity calendar did not align with their interests.
A resident with depression and dementia experienced undignified treatment from a CNA, who made inappropriate comments about the resident's incontinence and accused the resident of trying to get her fired. The facility's policy on dignity was violated, and the CNA was terminated following the incident. The resident reported feeling safe after the CNA's removal.
Unsafe Room Surfaces and Loose ICF Scale Support
Penalty
Summary
The facility failed to maintain resident rooms and equipment in a safe condition in 2 of 2 rooms reviewed, with missing and rough laminate observed on sink counters in Room 361 and Room 370. In Room 361, three areas of laminate were missing from the sink counter, each about 0.5 inches in diameter and rough to the touch. In Room 370, a large piece of laminate was missing from the sink counter, measuring about eight inches long by two inches high and also rough to the touch. Staff stated they had not noticed the damage and would notify maintenance if they did, and the Maintenance Director stated he was not aware of the missing laminate and that the edges needed to be smoothed to prevent potential skin injury. The facility also failed to maintain the ICF wheelchair scale used for resident weighing. Resident 104, who was admitted in 6/2023 with a diagnosis of stroke and had a care plan for cane use, stated during Resident Council that the support towel or collapsible column on the scale was really loose and made the resident feel off balanced. Observation showed the scale support column was loose and moved about one inch forward and back when touched. Staff stated the column had been loose for about six months, and the Maintenance Director stated no one had informed him that the scale column on the ICF was loose.
Failure to Monitor Medication Refrigerator Temperatures
Penalty
Summary
The facility failed to monitor temperatures in the medication refrigerators on the second, third, and fourth floors. Review of the refrigerator temperature logs for 6/1/26 through 6/25/26 showed multiple missing entries for both day and night or evening shifts on all three floors. On the second floor, no day shift temperatures were recorded for the entire review period, and night shift temperatures were missing on 6/3/26, 6/22/26, and 6/23/26. On the third floor, no day shift temperatures were recorded for the entire review period, and night shift temperatures were missing on 6/7/26 and 6/25/25. On the fourth floor, multiple day shift entries were missing, including 6/1/26, 6/2/26, 6/5/26, 6/14/26, 6/15/26, 6/16/26 through 6/22/26, and 6/25/26, and multiple evening shift entries were missing, including 6/7/26, 6/2/26, 6/6/26, 6/10/26, 6/12/26, 6/14/26, and 6/16/26 through 6/18/26. Staff stated that day shift and night or evening shift nurses were responsible for documenting refrigerator temperatures, and staff verified that vaccines were present in the refrigerators on all three floors. The PharMerica refrigerator temperature guidance in the record stated that CDC recommends twice daily temperatures if vaccines are present. The DNS confirmed that nurses were responsible for checking and documenting refrigerator temperatures in the medication storage rooms and stated that the documents were expected to be filled out and accurate, with immediate notification if temperatures were out of parameters.
Unlabeled and Undated Food in Resident Refrigerators
Penalty
Summary
The facility failed to prepare and handle food in a sanitary manner in 3 of 4 resident refrigerators reviewed for food service. During observation of the ICF 3 resident refrigerators, food items including hot dogs, buns, pizza snacks, pickles, potato salad, and a cup of melted ice cream were found unlabeled and undated. A CNA stated she was unsure of the process when a resident brought food in from an outside source, but thought staff were required to date and label residents' food, and was unsure how long food could remain in the refrigerator. The DNS later observed the items and confirmed residents' food was required to be labeled and dated, and staff were expected to follow proper labeling and dating procedures. In the ICF 4 resident refrigerators, feta cheese, lean cuisines, chicken and vegetable dumplings, two large boxes of hot pockets, olives, and broccoli were found unlabeled and undated. A CNA stated CNAs were responsible for labeling and dating residents' food and kitchen staff were responsible for ensuring food was not expired. In the SNF 1 resident refrigerators, three boxes of lean cuisine meals, a pint of Ben & Jerry's ice cream, yogurt, and an opened undated Red Bull were observed unlabeled and undated. A dietary aide stated he was trained to check refrigerators for dated and labeled food but was not trained to check freezer items for dating, labeling, or expiration. A cook stated he checked the resident's refrigerator and freezers daily and was unaware of any foods that needed to be removed, and the dietary manager stated staff were expected to check resident refrigerators and freezers daily and remove any food that was not dated or labeled.
Failure to Provide Timely Pain Medication After Knee Surgery
Penalty
Summary
The facility failed to ensure safe, appropriate pain management for a resident admitted after knee replacement surgery with diagnoses including aftercare following knee replacement surgery and pain. Hospital discharge instructions ordered oxycodone as needed and Tylenol at bedtime, but the last documented oxycodone administration on admission day was at 8:42 AM. That evening, the resident reported sharp left knee pain rated at five, with pain affecting sleep, social activities, physical activity, mobility, and emotions. The next documented oxycodone administration did not occur until the following day at 1:20 PM, when the resident reported pain rated at nine. Witnesses and staff stated the resident arrived at the facility in significant pain after surgery and did not receive pain medication until the next day. A friend stated the resident was in a lot of pain on arrival and was concerned that pain medication was not given until the following day. The resident stated staff told him/her they did not have the pain medication available and that the knee remained painful. A CNA reported overhearing a nurse tell the resident that pain medications were not available. The pharmacist stated staff did not order the oxycodone until the next day, and the RN confirmed the facility should have had the medication on hand, but only one tablet was available; the resident declined it because the full prescribed dose was not available. The RN also confirmed she did not document the refusal of the half dose, did not notify the physician, and did not assess the resident for pain, while the RNCM confirmed nurses were required to assess and address pain at admission and that the resident did not receive pain medication until after 1:00 PM the next day.
Failure to Obtain Ordered Stat Chest X-Ray
Penalty
Summary
The facility failed to ensure an ordered stat chest x-ray was obtained for a resident admitted with a diagnosis of pelvic fracture after an unwitnessed fall. Progress notes show the resident’s physician was notified on 3/1/26 that the resident had an unwitnessed fall and an oxygen saturation of 85 percent on room air; oxygen was applied and the saturation increased to 93 percent. The physician then ordered a stat chest x-ray, but the resident’s clinical record did not show that the x-ray was obtained on 3/1/26. During interviews, an RN stated that a stat x-ray was to be completed the day it was ordered and that if the x-ray technician could not come to the facility, the physician was to be notified. The DNS stated stat orders were to be obtained within four to six hours and that if they could not be obtained within that time, the physician was to be notified; the DNS also stated there was no x-ray obtained and no indication staff called the physician.
Delayed Resolution of Resident Grievances
Penalty
Summary
The facility failed to ensure that a resident’s grievances were completed in a timely manner for one cognitively intact resident who was admitted with a diagnosis of cancer. The resident, who attended resident council meetings, reported multiple grievances related to staffing and food services, another resident’s behaviors, and the manner in which other residents accessed an ice machine. The grievance follow-ups were not completed until weeks after the concerns were raised, and the resident stated that it took almost one month before the Administrator provided the written resolutions. The Administrator stated that when a resident filed a grievance, the department conducting the investigation was to provide a resolution within a week, and acknowledged that timely resolutions were not provided.
Failure to Follow and Clarify Physician Orders for Dialysis, Medications, and UTI Symptoms
Penalty
Summary
The facility failed to follow physician orders and clarify physician orders for residents receiving dialysis and nutrition-related care. For one resident admitted with asthma and diabetes, the record showed a 17-pound weight gain over four days, bilateral leg edema, and a provider note that included new orders for furosemide, labs, and a chest x-ray. The medical record later showed no evidence that the chest x-ray was completed. An RN stated she did not review the provider's notes, the RNCM stated she missed the note related to the chest x-ray and should have clarified whether it was to be completed, and the DNS stated staff were expected to clarify the order with the provider. For another resident with end stage renal disease on dialysis, high blood pressure, and immunodeficiency due to post kidney transplant, the care plan stated medications were to be held on dialysis days, but the medical record contained no orders to hold medications on dialysis days. The MAR showed multiple medications were held on dialysis days, including calcium acetate, torsemide, Protonix, nifedipine, aspirin, NPH insulin, finasteride, lactobacillus, nystatin swish and swallow, and multiple vitamins, and Envarsus was not given four times. The DNS stated the provider was not notified of the missed medications and that staff were expected to give medications as ordered, clarify questions with the provider, and notify the provider for any missed medications. A third resident reported burning with urination and concern for a possible UTI, but the clinical record did not show the physician was notified or that the resident was monitored for a possible UTI after the report. The resident was later hospitalized with altered mental status and pain with urination and diagnosed with a UTI, and the DNS stated the diagnosis and treatment were delayed.
Dialysis Port Not Monitored or Care Planned
Penalty
Summary
The facility failed to monitor a resident’s dialysis port and failed to care plan the dialysis port for 1 of 1 sampled resident reviewed for dialysis. Resident 131 was admitted with diagnoses including end stage renal disease and had care plans dated 6/14/26 for peritoneal dialysis, enhanced barrier precautions due to the peritoneal dialysis catheter, dialysis access through the peritoneal catheter, and peritoneal dialysis catheter care. However, no information was found on the care plan regarding the resident’s dialysis port. On 6/22/26, Resident 131 stated that he/she was doing peritoneal dialysis at home, but at the facility was doing hemodialysis through a chest port, and stated staff did not check the chest port. The medical record showed no indication that the chest port was being monitored. Staff 11 stated the resident had a chest port that she checked on dialysis days, but there was no order to check it. Staff 12 stated the resident did not have orders to monitor the chest port and was not care planned for monitoring, although staff were expected to check it every shift and document it in the TAR. Staff 2 acknowledged there were no orders or care plan for chest port monitoring and stated staff were expected to monitor the chest port before and after dialysis and every shift, with documentation in the TAR and care plan.
Failure to Assess Bedrail Use Before Placement
Penalty
Summary
The facility failed to assess a resident prior to implementing bedrails for 1 of 4 sampled residents reviewed for accidents. Resident 54 was admitted with a stroke and left-sided paralysis, later had moderate to severe cognitive impairment, and was assessed as not attempting to get out of bed independently because of the paralysis. The resident’s record included a device/mattress safety observation form identifying a bed rail, an order for bilateral one-quarter rails for mobility with monitoring for entrapment, a care plan noting use of one-quarter side rails for bed mobility, and a side rail consent form. However, the safety observation form did not identify the rail length and contained no additional information about the rail placement. During observation, Resident 54 was seen with bilateral one-quarter rails positioned in the middle of the bed, with the right leg over the rail on the left side of the bed. Staff stated the resident at times attempted to get out of bed without assistance, hallucinated, moved a lot in bed, and was often found in varying positions with a leg over the rail. Staff also stated the rails were usually used near the head of the bed, but there was no clear assessment or rationale for placing Resident 54’s rails in the middle of the bed. The resident stated the rails were hated, hurt the knees, and were frequently hit.
Menu Not Followed for Resident With Gluten-Free Diet
Penalty
Summary
The facility failed to ensure menus were followed for 1 of 5 sampled residents observed during dining observations. Resident 78 was admitted with diagnoses including aftercare following knee replacement surgery and pain, and had physician orders and care plan documentation indicating a gluten free diet due to Celiac disease and a gluten allergy. The record also noted additional food allergies, including melon, carrots, and bananas. Despite these documented dietary needs, the resident stated staff did not appear to understand Celiac disease and that meals inconsistent with the resident’s dietary needs were served for approximately four days after admission, even after nursing and dietary staff were notified. The resident stated friends brought food to the facility because the kitchen kept serving meals with gluten, and the friends confirmed they brought food because the facility continued to serve foods inconsistent with the resident’s dietary needs related to Celiac disease. An RN stated the resident was served foods inconsistent with the dietary needs on multiple occasions and that dietary staff said they had not received a dietary slip identifying the gluten free diet; the RN also stated the resident’s meal ticket did not indicate a gluten free diet for the first couple of days and she returned a breakfast tray because it was not gluten free. During surveyor observation, a regular and alternative test tray were requested, and the meal served was not consistent with the posted menu because beef stroganoff was served with orzo instead of the listed egg noodles. The Dietary Manager confirmed the meal served was not consistent with the posted menu and that the menu was not followed.
Food Not Palatable or Served at Proper Temperature
Penalty
Summary
The facility failed to provide palatable food to 2 of 5 residents reviewed for food, including a resident admitted with diagnoses of depression and anxiety and another resident admitted following knee replacement surgery with pain. Resident 19, who was cognitively intact, stated the food was too salty, did not look good, and was not good to eat. Resident 78 stated the food did not always taste good. The resident council minutes from 3/26/26 also showed residents expressed concerns that the food lacked flavor and was not palatable. Staff interviews and meal observations supported the concern. The Dietary Manager stated she was unaware of recent food complaints but acknowledged residents had previously expressed concerns about food being cold and not palatable. During surveyor observation of a regular and alternative test tray, the quesadilla was tough to chew along the edges, the cheese was not melted, and the broccoli was cold. The beef stroganoff with rice and a dinner roll was described as bland and lacking flavor, and the Dietary Manager confirmed the food was cold and not palatable and stated the beef stroganoff would have been improved with sour cream.
Failure to Follow EBP for Residents With Tube Feeding and Wounds
Penalty
Summary
The facility failed to ensure Enhanced Barrier Precautions (EBP) were followed for two residents who had tube feeding and pressure ulcers or wounds. One resident, admitted with a stroke diagnosis, had a care plan directing staff to use EBP for tube feeding, including wearing gowns and gloves for high-contact tasks such as bathing and personal hygiene. During observation, a CNA was seen entering and reentering the resident’s room without wearing a gown or gloves while assisting with personal hygiene and bathing, and later stated she had removed a cloth gown, summoned an LPN, then returned and put on a clean cloth gown to continue care. The LPN stated staff were to wear a disposable gown for EBP, and the Infection Preventionist and DNS stated a cloth gown was not appropriate for high-contact tasks under EBP. A second resident, admitted with pressure ulcers, chronic lower extremity wounds, and MDRO, had an active care plan for EBP related to chronic bilateral lower extremity wounds and a right rear thigh wound, with gown and glove use required for dressing, bathing, hygiene, toileting, linen changes, and wound care. Although an EBP sign and gowns were initially observed outside the resident’s room, multiple staff were later observed entering the room without PPE, and the sign had been removed. During wound care, an RN entered the room without performing hand hygiene, donned gloves but not a gown, and stated she was not aware a gown was needed for wound care. The Infection Preventionist stated the physician orders for EBP were still active and did not know why the sign and PPE had been removed.
Call Light Not Kept Within Reach
Penalty
Summary
The facility failed to ensure a call light was accessible to Resident 54, who was admitted with a diagnosis of stroke and whose care plan revised 3/25/26 identified the resident as at risk for falls and directed staff to remind the resident to activate the call light for assistance. On 6/23/26 at 8:23 AM, Resident 54's call light was not within reach until the Administrator entered the room and secured it within reach. On 6/24/26 at 9:12 AM, the resident was observed in bed with the call light not on the bed; an LPN entered the room and found the call light under the bed, stating it was to be secured to the resident's sheets or gown so it could be reached. Later that day, a CNA stated the resident was able to activate the call light, and the DNS stated residents were to have their call lights within reach.
Failure to Provide Ordered Nutritional Supplements Due to Administrative Delays and Supply Restrictions
Penalty
Summary
The facility failed to provide nutritional supplements as ordered for four out of five residents reviewed for nutritional supplements. Multiple residents with diagnoses such as dysphagia, malnutrition, Parkinson's disease, stroke, dementia, and failure to thrive had physician orders for Medpass 2.0, a nutritional supplement, to be administered multiple times daily. Medication Administration Records (MARs) for these residents showed repeated entries indicating the supplement was unavailable on several days during the review period. Staff interviews revealed that the Dietary Manager was responsible for ordering Medpass 2.0 but faced delays in administrative approval for purchase orders, as well as restrictions on the quantity that could be ordered due to budget limitations set by administration. These delays and restrictions resulted in insufficient supply and the supplement being unavailable for residents on multiple days. Nursing staff confirmed the supplement was often unavailable, and attempts to locate additional supply within the facility were unsuccessful. Residents and staff confirmed that the prescribed nutritional supplements were not received as ordered on the documented dates. The Director of Nursing Services (DNS) verified that the '9' notation on the MAR indicated the supplement was not available and confirmed the missed doses for each affected resident. The lack of timely administrative approval and supply limitations directly led to the failure to provide the ordered nutritional supplements.
Failure to Provide Timely ADL and Transfer Assistance Due to Staffing Shortage
Penalty
Summary
A deficiency occurred when a resident with diagnoses including breast cancer and congestive heart failure, who was cognitively intact and required two-person assistance for bed mobility and transfers, was not provided timely care according to her preferences and care plan. The resident preferred to go to bed between 4:30 PM and 5:00 PM, but on the evening in question, was not assisted to bed until approximately 9:00 PM. During this period, the resident remained in her wheelchair, resulting in pain in her legs and being soaked in urine by the time she was finally transferred to bed and changed. The delay was attributed to a staffing shortage, with only one CNA working on the floor for approximately four hours, responsible for 20 residents, several of whom required two-person assistance. Multiple staff interviews confirmed the staffing shortage and the resulting delay in care. The resident's grievance and statements from staff, including the RN, CNA, Resident Care Manager/LPN, and DNS, all acknowledged that the resident's needs and preferences were not met due to inadequate staffing. The incident was verified by the former administrator, who confirmed that the delay in care was a result of the staffing failure on that evening.
Failure to Ensure Safe Discharge with Home Health Services
Penalty
Summary
A resident with a fibular fracture was admitted to the facility and had a discharge care plan indicating an anticipated return home, with arrangements to be made for home health (HH), caregiver support, physical therapy (PT), and occupational therapy (OT). Physician and social services notes confirmed the need for these services, and a referral to a home health agency was initially sent. However, when the home health agency attempted to complete the referral, facility staff informed them to cancel it, as the resident was reportedly no longer planning to discharge at that time. Despite this, the resident was ultimately discharged home without a completed home health referral or the necessary support services in place. The resident reported being without caregiver supports until arranging services independently through their physician, and a family member had to quit two jobs to provide care until home health services were established. Facility leadership acknowledged that the resident was discharged without the required home health, PT, and OT services.
Failure to Dispose of Expired Medications
Penalty
Summary
The facility failed to properly dispose of expired medications across multiple medication storage areas, including three medication storage rooms, four medication carts, and one medication storage refrigerator. This oversight was identified during observations and interviews with staff members who acknowledged the presence of expired medications. The expired medications included nicotine transdermal patches, saline nasal spray, liquid cough suppressant, liquid acid reducer, vitamin C tablets, Vitamin A&D ointment, triple antibiotic ointment, and sodium chloride tablets. Additionally, multi-dose vials of Tuberculin were found without open dates, contrary to manufacturer instructions that require them to be dated and discarded after 30 days. Staff members admitted to not knowing the facility's medication storage policy, which contributed to the failure to discard expired medications. The facility's policy, last revised in November 2020, did not specifically address the handling of vials of medications, although it did state that outdated medications should be destroyed. Staff 3 confirmed that the expectation was for all staff handling medications to be familiar with and adhere to the medication storage policy, which includes destroying expired medications and ordering replacements if necessary.
Improper Food Labeling and Storage in Facility
Penalty
Summary
The facility failed to ensure proper labeling and storage of food items in the kitchen and dining room refrigerator units and freezers, which could lead to foodborne illness and unappetizing meals for residents. During observations, surveyors found unlabeled and undated food items, including a plastic-wrapped stainless steel container with white filets, frozen red patties, and an open bag of croutons in the main kitchen. Staff 4, the Dietary Manager, acknowledged these issues and stated that food items were expected to be labeled and dated with the date they were prepared or opened. Additionally, dented cans of apple pie filling, black beans, and diced peaches were found in the dry storage room, which Staff 4 admitted should have been removed from the pantry. On the second floor Intermediate Care Facility (ICF) unit, an unopened package of expired frozen purple Ube steamed buns was found in the freezer, unlabeled and undated. Staff 25, a CNA, was unable to confirm ownership of the package and acknowledged the expiration date. Staff 18, an LPN Resident Care Manager, confirmed the expired package and stated that dietary staff were responsible for cleaning out and monitoring refrigerator contents. Staff 20, another CNA, explained that it was the staff's responsibility to label and date resident food items before placing them in the unit refrigerator. Similar issues were observed on the third and fourth floors of the ICF building, where several unlabeled and undated food items were found in the refrigerators and freezers. These included a vanilla nutritional supplement, a tumbler with white liquid, a plastic container with red chunks, sour cream, frozen blueberries, and homemade popsicles. Staff 19, a CNA, acknowledged the unlabeled and undated items, while Staff 18 and Staff 20 reiterated the responsibility of dietary staff and CNAs in maintaining proper labeling and dating of food items. Staff 4, the Dietary Manager, confirmed that dietary staff were expected to restock and check refrigerators daily, discarding expired products to prevent health hazards for residents.
Misappropriation of Resident's Oxycodone Tablets
Penalty
Summary
The facility failed to ensure that a resident was free from misappropriation of their medications, specifically Oxycodone tablets. The resident, who was cognitively intact and admitted with a hip fracture and lung disease, was discharged with instructions to take home all their medications, including 112 Oxycodone tablets. However, upon discharge, the resident reported that 56 Oxycodone tablets were missing from the bag of medications they received. Despite the resident's report to a staff member, the issue was not escalated to upper management, and the missing tablets were not accounted for. The facility's records showed discrepancies, with a narcotic logbook indicating the resident signed for all 112 tablets, yet a destruction log showed that 56 tablets were destroyed by facility staff. Staff members involved in the discharge process and subsequent communication with the resident failed to report the missing medication to upper management. The Director of Nursing Services and other staff were unaware of the issue until months later, acknowledging that the tablets should have been sent home with the resident and expressing uncertainty about why the tablets were destroyed.
Failure to Report Misappropriation of Medications
Penalty
Summary
The facility failed to report an incident of alleged misappropriation of medications to the State Agency in a timely manner, as required by their policy. A resident, who was cognitively intact, was discharged from the facility with a stapled paper bag containing their belongings and medications. Upon arriving home, the resident discovered that the Oxycodone tablets they had signed for were missing. The resident reported the missing medication to a Licensed Practical Nurse (LPN) at the facility, who confirmed that the Oxycodone was placed in the bag but failed to escalate the issue to upper management or the State Agency. Additionally, a Certified Medication Aide (CMA) was aware of the resident's report of the missing Oxycodone but also did not report the incident to upper management or the State Agency. The Director of Nursing Services (DNS) stated that it was her expectation for staff to report such allegations to her or a Resident Care Manager. However, the DNS was only made aware of the incident several months later, indicating a breakdown in the facility's reporting procedures. This failure to report placed residents at risk for diversion of medications and misappropriation of property.
Failure to Assess Residents for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to assess two residents for the safe self-administration of medications, which placed them at risk for an unsafe medication regimen. Resident 65, admitted with kidney failure, was observed with tubes of Zinc Oxide External Paste and Hydrocortisone External Cream at her/his bedside, which she/he used as needed. Despite having a BIMS score indicating cognitive intactness, there was no evidence in the health record that Resident 65 was assessed for self-administration of these medications. Staff confirmed the lack of assessment and removed the medications from the resident's room. Similarly, Resident 69, admitted with dementia and diabetes, was found with cough drops at her/his bedside, which she/he used frequently. Although Resident 69 also had a BIMS score indicating cognitive intactness, there was no documentation of an assessment for the safe self-administration of cough drops. Staff were unaware of the resident's use of cough drops and removed them upon discovery, confirming that no assessment had been completed to ensure safety.
Failure to Provide Transfer Assistance for Resident
Penalty
Summary
The facility failed to ensure that a resident, who was unable to perform activities of daily living (ADLs) independently, received the necessary transfer assistance. The resident, admitted with conditions including hemiparesis, hemiplegia, and aphasia following a stroke, was dependent on staff for transfers as indicated in their admission MDS. Despite having a care plan that required the use of a mechanical lift for all transfers and a tilt-in-space wheelchair provided by therapy, the resident was observed to remain in bed over several days without being transferred to their wheelchair. Interviews with staff revealed confusion and miscommunication regarding the resident's transfer assistance. Family members and staff expressed a desire for the resident to be transferred to their wheelchair, as the resident enjoyed being around people and out of their room. However, some staff believed that only therapy staff were allowed to perform the transfers, while others were unsure of the reasons behind this restriction. The Director of Rehabilitation confirmed that there was no directive from the therapy department to keep the resident in bed, and the Director of Nursing Services acknowledged the lack of transfer assistance, expecting nursing staff to provide such assistance and to reapproach the resident if they initially refused.
Failure to Provide Individualized Activity Programs
Penalty
Summary
The facility failed to provide an ongoing program to support individual activity interests and preferences for two residents, placing them at risk for isolation and lack of social interaction. Resident 72, admitted with diagnoses including colon cancer and adjustment disorder with anxiety and depression, had specific activity preferences such as listening to classical music, reading non-fiction books, and going outside. However, from February to March, the resident did not participate in any group or self-directed activities and received minimal one-to-one visits. Observations revealed the resident was often in bed with the television on, and staff were unaware of the resident's interests, failing to offer activities like book reviews or outdoor time. Resident 90, admitted with hemiparesis, hemiplegia, and aphasia following a stroke, also experienced a lack of tailored activities. The resident's care plan indicated a preference for in-room activities, classical music, and going outside. However, the resident participated in only one group activity and received limited one-to-one visits. Observations showed the resident spent most of the time in bed watching television, with no evidence of being offered opportunities to go outside or engage in preferred activities. Staff interviews revealed a lack of awareness and action regarding the resident's interests and needs. The facility's activity calendar showed scheduled activities, but these did not align with the specific interests of Residents 72 and 90. Staff, including the Activities Director, acknowledged the failure to offer activities tailored to the residents' preferences. The lack of individualized activity programming and staff engagement contributed to the deficiency, as residents were not encouraged or assisted to participate in activities that matched their interests and capabilities.
Failure to Provide Dignified Care to Resident
Penalty
Summary
The facility failed to provide dignified and respectful care to a resident diagnosed with depression and dementia. The resident reported an incident involving a CNA, identified as Staff 3, who allegedly yelled at the resident and made undignified comments about the resident's incontinence. The resident expressed fear and confusion regarding the CNA's behavior, which included accusations of the resident trying to get the CNA fired and comments about the resident's incontinence. These actions were contrary to the facility's policy on dignity, which emphasizes treating residents with respect and enhancing their sense of well-being. The incident was documented in an Alleged Abuse report, and it was noted that the resident felt safe after the CNA was terminated. Interviews with staff revealed that the CNA had a history of making undignified statements to residents, and the incident with this resident was considered the final concern regarding respect and dignity. The facility's administrator confirmed that the CNA's statements were undignified, and the previous Director of Nursing Services acknowledged the resident's sensitivity and the inappropriate nature of the CNA's comments.
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.
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What surveyors actually found near you
We read the 551 citations issued within 25 miles in the last 12 months — including the 3 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) |
|---|---|---|---|---|
| Belmont Care And Rehabilitation | 1 mi | ★★★★★ | 8 | 0 |
| Providence Child Center | 1.2 mi | ★★★★★ | 0 | 0 |
| Holladay Park Plaza | 1.3 mi | ★★★★★ | 1 | 0 |
| Mt. Tabor Health & Rehabilitation | 1.5 mi | ★★★★★ | 13 | 0 |
| Reedwood Post Acute | 1.7 mi | ★★★★★ | 0 | 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 October 2026) and official state health department websites.