Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Laurelhurst Post Acute & Rehabilitation during CMS and state inspections, most recent first.
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.
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.
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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) |
|---|---|---|---|---|
| Belmont Care And Rehabilitation | 1 mi | ★★★★★ | 0 | 0 |
| Providence Child Center | 1.2 mi | ★★★★★ | 2 | 0 |
| Holladay Park Plaza | 1.3 mi | ★★★★★ | 4 | 0 |
| Mt. Tabor Health & Rehabilitation | 1.5 mi | ★★★★★ | 7 | 0 |
| Reedwood Post Acute | 1.7 mi | ★★★★★ | 0 | 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.