Average — CMS composite of the measures below.
The next survey window likely opens around November 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 Porthaven Post Acute during CMS and state inspections, most recent first.
Resident Council grievances and complaints were not promptly addressed for several months. Minutes showed concerns about call light wait times, CNA staffing, language barriers, and dietary issues, but there was no evidence the concerns were resolved. Several residents stated their concerns were not followed up beyond discussion with the department head, and the Administrator acknowledged the need for a more effective process for timely communication and grievance completion.
Unclean Communal Toilet and Shower Rooms: A resident reported foul odors and feces on toilet seats in shared bath areas. Surveyors repeatedly observed urine odor, brown material on toilet seats and shower chairs, soiled towels and washcloths on the floor, and shower room doors left open while the rooms remained unclean. Staff interviews confirmed CNAs and housekeeping were not consistently disinfecting the communal toilet/shower rooms after use, and disinfectant was available but not always used.
Failure to develop and implement a resident-centered activity program for a resident with dementia and mild cognitive impairment. The resident's MDS identified listening to preferred music as a very important activity, but no activity care plan was in the chart, no music-themed activities were documented, and staff CNAs said they did not know the resident's activity interests. The Activity Director stated music was a big activity for the resident but acknowledged nothing was listed on the care plan.
A resident with morbid obesity, diabetes mellitus, and an open foot wound missed ordered weekly Tirzepatide injections after the final dose was given and the refill was delayed. The resident said the medication was important for weight loss and therapy participation, while staff reported the refill was awaiting approval, the pharmacy may have run out or the drug was high cost, and the facility's contingency plan for stat meds and an interim alternate medication was not followed.
A resident with dementia and right-sided hemiplegia after a stroke had significant mobility and ADL impairment, but the record showed no care plan for the resident's right-sided weakness. Staff observed the resident's right hand curled into a contracture, with fingers pressed into the palm and the thumb tightly against the index finger. The resident said the facility had done nothing for the hand contracture and wanted a rolled washcloth or therapy carrot. A CNA placed rolled gauze in the hand, while the rehab director said a splint had been ordered and staff were to use a hand roll until it arrived, but other staff were not informed and the assigned nurse was unfamiliar with the contracture.
Failure to supervise smoking and secure smoking materials for a resident with cognitive impairment and a hx of intracerebral hemorrhage. The resident’s assessment and care plan required supervised smoking, use of a smoking apron, and locked storage of smoking paraphernalia, but the resident was observed with a cigarette in the room and said another resident provided cigarettes. Several CNAs and an RN stated they did not know the resident needed supervision or where the smoking materials were stored, while the resident reported staff did not supervise or assist during smoking.
Improper handling of meal trays and dairy items in resident room: A resident with anxiety disorder and PTSD requested that meal trays be left in the room, and staff honored that preference even though milk, yogurt, and other food items were often left for several hours or overnight. Surveyors observed multiple trays in the room with partially full glasses of milk and opened yogurt containers, and staff could not provide documentation of education about the risks of consuming dairy left at room temperature for more than two hours.
A resident with congestive heart failure and delusional disorders was discharged to a home lacking basic utilities and infested with rats, despite prior IDT concerns and without the primary physician's involvement in discharge planning. Documentation did not show that the IDT met to ensure a safe discharge, and facility leadership could not provide further information.
A resident with a known history of violent behavior was not care planned for these risks and subsequently physically assaulted another resident, causing serious injuries including a spinal fracture and prolonged severe pain. The injured resident, previously independent, became bedridden and required increased pain management following the incident. Staff confirmed the event as abuse and noted the significant decline in the resident's condition.
A resident with a history of infective endocarditis had incomplete and missing wound assessments in their medical record, with several assessments lacking key details such as measurements and wound descriptions. Nursing staff also failed to document the resident's refusals of wound care, despite facility policy requiring such documentation. Staff interviews confirmed these documentation lapses.
A resident with a chronic open wound was not placed on enhanced barrier precautions upon admission, and staff did not consistently use required PPE, such as gowns, during wound care. Proper precautions and signage were only implemented after the deficiency was observed, contrary to facility procedures.
A resident with severe cognitive impairment was sexually abused by another resident in a TV area. The facility's records lacked a Sexual Consent Form for both residents involved. Staff intervened immediately, separating the residents and assessing them for injuries. The facility's administrator acknowledged the incident as sexual abuse.
The facility failed to follow infection control standards, including improper disinfection of glucometers and inadequate use of PPE for a resident with open wounds. Staff did not consistently perform hand hygiene, leading to potential exposure to infectious diseases.
The facility failed to maintain a homelike environment, with surveyors identifying cracked light covers, non-functional lights, dirty vent covers, and sharp/jagged edges on walls and corners across multiple halls. These deficiencies were acknowledged by the Administrator and Maintenance Director.
The facility failed to accurately assess two residents for oxygen therapy and wound care. One resident with COPD had inconsistent MDS documentation regarding their need for supplemental oxygen, despite receiving it. Another resident with diabetes had a diabetic foot ulcer misdocumented as a surgical wound in their MDS. These inaccuracies were confirmed by nursing staff.
The facility failed to update care plans for two residents, leading to discrepancies in respiratory care and weight monitoring. One resident received continuous oxygen therapy at a rate not reflected in their care plan, while another had conflicting instructions for weight monitoring. Staff confirmed the care plans did not match current physician orders, placing residents at risk for unmet needs.
The facility failed to involve two residents and their representatives in the care planning process. One resident with dementia had not had a care conference since February, despite the facility's quarterly schedule. Another resident with acute respiratory failure and cognitive decline had no documented care conference since January, with staff unable to confirm a June conference or representative involvement.
A facility failed to notify the State LTC Ombudsman about a resident's hospitalization, as required for advocacy. The resident, admitted with a UTI and bacteremia, was discharged to a hospital, but there was no documentation of Ombudsman notification. The facility administrator confirmed the oversight.
The facility failed to provide two residents with a written notice of the bed hold policy when they were transferred to a hospital due to changes in their medical conditions. This omission was confirmed by the Administrator and Interim DNS, highlighting a lack of documentation in the residents' health records.
A resident with hemiplegia did not receive necessary nail care services as required by physician orders. Despite records indicating nail care was not needed or refused, the resident later stated they would not have refused if offered. Observation confirmed the resident's nails were long and dirty, and staff acknowledged the lack of care.
The facility failed to provide timely antibiotic treatment for a resident with infected wounds due to delayed communication of culture results, and did not notify the physician of significant weight gains. Another resident experienced a medication error when sertraline was not added to the MAR upon readmission, leading to increased behaviors. These deficiencies highlight lapses in following physician orders and timely communication.
The facility failed to implement necessary fall prevention measures and conduct thorough investigations for two residents. One resident, with a history of falls and an amputation, experienced an unwitnessed fall, and the care plan was not followed. Another resident, found on the floor after attempting to go to the bathroom, had an incomplete investigation lacking witness statements. Staff acknowledged the investigations were not thorough, and the care plans were inaccurately documented.
A facility failed to follow physician orders for a resident requiring respiratory care, specifically in the administration of humidity mist via a tracheostomy. The resident had a physician order for humidity mist at a flow rate of eight liters per minute, but it was observed to be set at four liters per minute. This discrepancy was confirmed by the Interim DNS.
A facility failed to employ a PT to provide necessary therapy services to a resident with multiple left toe fractures. Despite hospital orders for PT evaluation and services, the resident did not receive PT from August 6 to August 13 due to the facility's inability to maintain a consistent PT. The Rehabilitation Director confirmed the reduction in therapy services for all residents.
A facility failed to coordinate and document hospice services for a resident with failure to thrive and acute kidney failure. Despite the resident's admission to hospice services, there was no documentation in the health record, and staff were unaware of hospice care details. The Social Services Director and a CNA lacked information on hospice involvement, and an RNCM confirmed the absence of hospice documentation.
A resident's grievance about missing personal property was not addressed by the facility. Despite a complaint being made after the resident's discharge, staff members, including the Social Services Director and LPN Resident Care Manager, were unaware of the issue. The grievance was not recorded in the facility's binder, and the receptionist, who received the complaint, did not report it to management. The administrator and grievance officer were also not informed, highlighting a failure in the grievance reporting process.
The facility failed to provide adequate staffing, resulting in delayed and unmet resident care needs and lengthy call light response times. Observations and interviews revealed multiple instances of call lights not being promptly answered, with wait times ranging from 25 minutes to over an hour and a half. Staff and residents reported consistent short-staffing, leading to missed showers, increased falls, and long wait times for assistance.
Resident Council Grievances Not Promptly Addressed
Penalty
Summary
The facility failed to promptly respond to grievances and complaints raised by the Resident Council for three of four months reviewed. An undated Resident Council Policy stated that a Resident Council Response Form would be used to track issues and their resolution, that the affected department would be responsible for addressing concerns, and that the QAPI Committee would review Resident Council information and feedback as part of quality review. A review of the grievance book from 1/2025 through 11/2025 showed no grievances submitted by the Resident Council. Resident Council minutes from 8/2025 through 11/2025 documented multiple concerns, including call light wait times, inadequate CNA staffing on the floor, language barriers, and dietary concerns raised during old and new business, but there was no evidence the concerns or grievances were addressed. During an interview, seven of twelve Resident Council members stated concerns and suggestions brought up in council meetings were not followed up or addressed beyond discussion with the department head. Staff stated that concerns were brought to the Administrator, who would speak with department heads, and that the Activity Director was responsible for documenting concerns, notifying departments, following up on outcomes, and reporting back to the Resident Council. The Administrator acknowledged the need for a more effective process to address concerns and timely communication, while the Social Services Director stated she did not receive grievances from the Resident Council and that the Resident Council concerns were handled through a separate process.
Unclean Communal Toilet and Shower Rooms
Penalty
Summary
The facility failed to provide a clean and sanitary environment in communal toilet/shower rooms for 3 of 4 communal resident bathrooms reviewed for homelike environment. The facility policy titled Cleaning and Disinfection Environment Surfaces, adopted on 8/1/24, stated environmental surfaces are to be cleaned and disinfected according to CDC recommendations and OSHA Bloodborne Pathogens Standard, using an EPA-registered hospital disinfectant when there is uncertainty about soil or multi-drug-resistant organisms. Resident 11 was admitted with atherosclerosis of the left lower leg with ulceration and a right above-knee amputation. The MDS dated [DATE] showed a BIMS score of 15, indicating the resident was cognitively intact, and the resident was independent with toilet hygiene and toilet transfers. In interview, Resident 11 stated the communal toilet/shower rooms smelled and often had feces on the toilet seats, and that multiple communal toilet and shower rooms were used for toileting and showering. Observations from 12/2/25 through 12/5/25 showed repeated unclean conditions in the communal shower/toilet rooms, including urine odor, brown material on toilet seats and shower chairs, saturated towels and washcloths on the floor, matted hair on a grab bar, crumpled paper towels on the floor, and shower room doors left open while the rooms remained unclean. Staff were observed spraying soiled areas with water but not disinfecting them, leaving brown material on shower chairs and toilet seats after use. Staff interviews confirmed CNAs and housekeeping were not consistently cleaning and disinfecting the communal bath/shower rooms after resident use, that disinfectant was available but not always used, and that unclean rooms were sometimes left open for resident use before being cleaned.
Failure to Develop Resident-Centered Activity Plan
Penalty
Summary
The facility failed to develop and implement a resident-centered activity program for one resident who was admitted with dementia and whose admission MDS indicated mild cognitive impairment. The MDS also identified listening to preferred music as a very important activity for the resident, and the Activities CAA indicated an activity care plan would be created and updated as needed. However, the resident's clinical record contained no activity care plan, and the Activity Task Records from 11/9/25 to 12/8/25 showed no participation in any music-themed activities. Random observations from 12/2/25 through 12/5/25 showed the resident in the room in bed, and no music was observed to be playing in the room. On 12/3/25, the resident stated a preference to spend time in the room and said the resident loved to listen to music, especially Christmas music, but had not been able to do so since admission. Staff interviews on 12/8/25 showed multiple CNAs did not know the resident's activity interests and relied on the care plan for that information, while the Activity Director stated music was a big activity for the resident but acknowledged the resident did not have anything listed on the care plan.
Missed Tirzepatide Doses
Penalty
Summary
The facility failed to follow physician orders for a resident admitted in 10/2025 with an open wound on the right foot and morbid obesity. The resident's admission MDS dated 10/12/25 showed moderate cognitive impairment and dependence for bed mobility, transfers, and toileting hygiene. Signed physician orders dated 10/14/25 directed that the resident receive 0.5 mL of Tirzepatide subcutaneously every seven days for diabetes mellitus and weight management, but the medication administration record showed the resident did not receive the ordered injections on 11/19/25, 11/26/25, and 12/3/25. A progress note dated 11/19/25 stated the resident was given the final weekly dose and a new order was placed for the next dose. On 12/3/25, the resident stated the Tirzepatide had been received weekly until 11/13/25 and that the medication was important for weight loss so the resident could participate in therapy and improve strength and overall health. Staff stated the resident missed doses because the refill was awaiting approval, the pharmacy may have run out or the medication was high cost, and the pharmacy was looking for an alternative. The DNS stated the facility had a contingency plan to call the pharmacy for stat medications and to contact the physician for an alternate medication in the interim, but this plan was not followed.
Failure to Address Hand Contracture and ROM Needs
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent further decreases in range of motion for one sampled resident with right-sided hemiplegia following a stroke. The resident was admitted with diagnoses including dementia and hemiplegia, and the admission MDS showed mild cognitive impairment with upper and lower extremity impairment on one side of the body. A progress note documented significant mobility and ADL impairment and persistent right-sided hemiplegia. However, no evidence was found in the clinical record that a care plan was developed to address the resident's right-sided weakness. Observations on multiple days showed the resident in bed with the fingers of the right hand pressed into the palm and the right thumb pushed tightly into the index finger. When the resident attempted to open the right hand, only slight movement of the index and middle fingers was possible, and the resident stated the facility had done nothing for the hand contracture and expressed interest in a rolled washcloth or a therapy carrot. Later, a small piece of rolled gauze was observed in the right hand, and the resident said she/he was happy to have something placed there. Staff interviews showed one CNA did not know about the contracture, another CNA placed rolled gauze in the hand because the fingers were curled, the DON of Rehabilitation stated a splint had been ordered and staff were to use a hand roll until it arrived but that other staff were not informed and no care plan was created, and the assigned nurse stated she was unfamiliar with the resident's hand contracture and would look in the care plan for information.
Failure to Supervise Smoking and Secure Smoking Materials
Penalty
Summary
The facility failed to ensure adequate supervision and proper securing of smoking materials for one resident who was reviewed for accidents. The facility’s smoking policy stated that residents who do not meet criteria to smoke independently are to be aided or supervised during smoking activities, residents are not allowed to borrow cigarettes or other smoking materials from other residents, and all smoking materials are to be locked up, including for residents assessed as supervised smokers. The resident was admitted with diagnoses including intracerebral hemorrhage and was described on the admission MDS as mildly cognitively impaired and not using tobacco. A smoking assessment later identified the resident as cognitively impaired, a cigarette smoker who could not light the smoking device independently and required supervision when smoking. The care plan directed supervision while smoking, use of a smoking apron, and storage of smoking paraphernalia per facility procedure. However, the resident was observed holding an unlit cigarette in the room and stated a friend at the facility provided cigarettes. Multiple staff members stated they did not know whether the resident required supervision, believed the resident smoked independently, or did not know where smoking materials were supposed to be stored. The resident also stated staff did not supervise or help when smoking and that the resident did not wear an apron when smoking. One staff member stated the resident’s smoking materials were kept in the nightstand drawer, jacket, or wheelchair pouch, while another staff member stated the materials were supposed to be locked up.
Improper handling of meal trays and dairy items in resident room
Penalty
Summary
The facility failed to practice proper food safety techniques for 1 of 4 residents reviewed for food. Resident 5 was admitted with diagnoses including anxiety disorder and PTSD, and the care plan updated 8/25/25 included interventions for room cleaning, including asking the resident if the room could be cleaned and ensuring safe/sanitation in the room. The record review found no specific documentation that Resident 5 was educated about the risks of keeping meals in the room for extended periods or that alternate techniques were attempted to maintain safety while accommodating the resident’s food preferences. On 12/1/25, four food trays were observed in Resident 5’s room, and three of the trays had full or partially full glasses of milk; opened yogurt containers were also observed on multiple trays. On 12/4/25, Resident 5 stated that food trays were requested to be left in the room and that food and drinks, including milk and yogurt, were often consumed several hours after delivery and sometimes overnight. Staff later confirmed that Resident 5 often saved food overnight and that the resident’s preference for leaving trays in the room was being honored, but no detailed education was provided regarding the risk of consuming dairy products left at room temperature longer than two hours. On 12/8/25, three food trays were again observed in the room, including one tray with meat and a glass of milk, and the meal ticket showed the tray was from dinner on 12/7/25.
Failure to Ensure Safe Discharge Planning
Penalty
Summary
The facility failed to ensure a safe discharge for one resident who was readmitted with congestive heart failure and delusional disorders. The resident was discharged to a family home that lacked running water, electricity, and heat, and was infested with rats. The primary physician reported not being included in discharge planning or informed of the discharge, and the former Social Services Director confirmed discouraging the discharge due to unsafe conditions. Clinical records showed an earlier interdisciplinary team (IDT) meeting determined it was unsafe to discharge the resident, and a social history review documented the resident's preference to return home despite the risks. However, there was no documented evidence that the IDT met to ensure a safe discharge at the time of the resident's release, and facility leadership could not provide additional information regarding the unsafe discharge.
Failure to Protect Resident from Physical Abuse Resulting in Injury and Decline
Penalty
Summary
The facility failed to protect a resident from physical abuse, resulting in significant harm. One resident with a history of violent behavior, as noted in an email from the prior interim DNS, was not care planned for these behaviors, and no interventions were documented to address the risk. This resident physically assaulted another resident in a hallway, pushing the individual to the ground and punching them, which was witnessed by staff and required immediate intervention to separate the two. The assaulted resident, who had a history of multiple spinal fractures and mild cognitive impairment, sustained a lumbar spinal fracture, rib pain, and difficulty breathing as a result of the incident. Following the assault, the resident experienced severe and prolonged pain, as documented in pain records and medication administration records, requiring increased pharmaceutical interventions including acetaminophen, ibuprofen, oxycodone, fentanyl, and morphine. The resident's condition deteriorated, becoming bedridden, refusing care and medications, and exhibiting increased confusion and agitation. Multiple staff interviews confirmed that the resident was previously independent and ambulatory but became bedridden and in significant pain after the incident. Staff also confirmed that the incident was considered assault and abuse. The facility's failure to address the known violent behaviors of the aggressor resident and to implement appropriate care planning and interventions directly led to the physical abuse and subsequent decline of the victim resident.
Incomplete Wound Assessment Documentation and Failure to Record Care Refusals
Penalty
Summary
The facility failed to maintain accurate and complete documentation of wound assessments and care refusals for one resident with a history of acute and subacute infective endocarditis. The resident's medical record showed gaps in weekly wound assessments, with no documentation between certain dates, and several assessments were incomplete, missing critical information such as wound measurements, descriptions, and wound type. Additionally, refusals of wound care by the resident were not documented in the medical record as required by facility policy. Interviews with nursing staff confirmed that wound assessments were not fully completed and that refusals of care were not consistently documented. Staff acknowledged that the assessment forms were not always filled out after wound care was provided, and that documentation of interventions and resident responses to refusals was lacking. These actions and omissions resulted in incomplete and inaccurate medical records for the resident.
Failure to Implement Enhanced Barrier Precautions for Chronic Wound
Penalty
Summary
The facility failed to follow infection control standards for a resident with a chronic open wound to the left foot. Upon admission, there was no documentation in the clinical record indicating that enhanced barrier precautions were implemented for the resident, despite facility procedures requiring such precautions for conditions like chronic wounds. During an observed dressing change, staff placed an enhanced barrier precaution sign on the resident's door and donned appropriate PPE, but it was confirmed that prior to this, staff had not consistently worn the required PPE, such as gowns, when providing care. The resident reported that this was the first time staff had worn PPE gowns during wound care since admission. Staff interviews confirmed that enhanced barrier precautions should have been in place from admission, including signage and PPE use, but these measures were not implemented until the day of observation.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse by another resident. The incident involved two residents, one with Alzheimer's disease and the other with a genetic disorder causing developmental and intellectual disability. The resident with Alzheimer's was cognitively intact according to their MDS, while the other resident had severe cognitive impairment. The facility's records showed no evidence of a Sexual Consent Form being completed for either resident. An incident occurred where one resident was observed rubbing the genitalia of the other resident in a TV area, which was immediately reported and the residents were separated. The facility's staff, including an LPN and an RN, assessed both residents for injuries, and none were noted. The incident was reported, and both residents were placed under monitoring, with one resident receiving 1:1 supervision. The facility's administrator acknowledged the occurrence of sexual abuse. The facility's policies on abuse and sexual consent were not effectively implemented, as evidenced by the lack of a Sexual Consent Form and the occurrence of the incident.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to infection control standards, particularly in the use of glucometers and the management of residents with wounds. Staff 32, an agency RN, was observed using a glucometer on two residents with diabetes without properly disinfecting it according to the manufacturer's instructions. Instead of using the recommended CaviWipe towelettes, Staff 32 used alcohol prep pads, which are not effective against bloodborne pathogens. This practice was confirmed by the facility's Infection Preventionist, who was unsure of the effectiveness of alcohol wipes against such pathogens. Additionally, the facility did not follow its own Transmission Based Precautions Policy for a resident with open and draining wounds. Staff 24 was observed transporting the resident without wearing the required personal protective equipment (PPE) such as gloves and a gown. The resident's wounds were uncovered, and a trail of fluid was left on the floor, which was not promptly cleaned, leading to multiple staff and residents stepping in it. Staff 15 and other CNAs acknowledged the lack of proper PPE use and the failure to manage the resident's leaking wounds effectively. The facility also failed to enforce its Hand Hygiene Policy. Staff members were observed not performing hand hygiene after touching their masks, between assisting residents, or after handling dirty food trays. Staff 26 and Staff 27 admitted to not consistently performing hand hygiene, and Staff 13 stated she was not taught to clean her hands between picking up dirty trays. The facility's administration confirmed that staff were expected to perform hand hygiene when entering and exiting resident rooms and after touching potentially contaminated surfaces.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment for residents, as observed during a survey conducted from August 12 to August 16, 2024. The survey identified several environmental deficiencies across three of the four halls reviewed. These included a cracked light cover with missing chunks near a room on the annex hall, non-functional lights in the annex hall and dining room, and dirty vent covers in multiple rooms and hallways. Additionally, there were several instances of torn or jagged baseboards and broken plastic wall protectors with sharp edges in various locations, including near the O2 storage closet, emergency exit, and the entrance to the clean laundry area. The surveyors noted that these environmental issues posed a risk of residents living in an unkempt environment. The presence of sharp and jagged edges on walls and corners, as well as non-functional lighting, could potentially compromise the safety and comfort of the residents. On August 16, 2024, the facility's Administrator and Maintenance Director acknowledged these concerns during the survey, indicating awareness of the deficiencies identified.
Inaccurate Assessments for Oxygen Therapy and Wound Care
Penalty
Summary
The facility failed to accurately assess two residents for oxygen therapy and wound care, leading to deficiencies in their care. Resident 22, who was admitted with diagnoses including a heart attack and chronic obstructive pulmonary disease, had physician orders for supplemental oxygen therapy at varying levels over several months. However, the resident's Minimum Data Set (MDS) assessments from June to August did not reflect the need for supplemental oxygen, despite multiple observations confirming the resident was receiving it. This discrepancy was acknowledged by a registered nurse case manager, indicating an oversight in accurately documenting the resident's oxygen therapy needs. Resident 37, readmitted with conditions such as diabetes and peripheral vascular disease, had a diabetic foot ulcer noted in podiatry outpatient notes. However, the resident's July MDS inaccurately documented the presence of a surgical wound instead of a diabetic foot ulcer. This inaccuracy was confirmed by the Director of Nursing Services and the Interim Director, highlighting a failure in the assessment process for the resident's wound care needs.
Inaccurate Care Plans for Respiratory Care and Weight Monitoring
Penalty
Summary
The facility failed to ensure that care plans were accurately revised to reflect the current needs of residents, specifically for two residents reviewed for respiratory care and unnecessary medications. Resident 22, who was admitted with diagnoses including a heart attack and chronic obstructive pulmonary disease, had a discrepancy between the physician's order and the care plan regarding supplemental oxygen therapy. The physician's order from July 2024 indicated that the resident should receive oxygen therapy at 2 to 4 LPM continuously, while the care plan from May 2024 stated oxygen should be administered at 2 LPM as needed. Observations in August 2024 showed the resident receiving oxygen at 3 LPM continuously, and staff confirmed the care plan did not match the current orders. Similarly, Resident 28, admitted with heart failure, had conflicting instructions regarding weight monitoring. The care plan from May 2024 indicated weekly weighing, whereas the physician's orders from August 2024 required daily weighing. A CNA expressed uncertainty about the correct frequency, relying on the care plan for guidance. The Interim DNS confirmed the need for the care plan to be updated to reflect the physician's orders. These discrepancies placed residents at risk for unmet needs due to inaccurate care plans.
Failure to Involve Residents in Care Planning
Penalty
Summary
The facility failed to involve residents and their representatives in the care planning process, as evidenced by the cases of two residents. Resident 4, who was admitted in May 2009 with a diagnosis of dementia, had not had a care conference since February 2024, despite the facility's policy of conducting these conferences quarterly. Staff confirmed that Resident 4 was overdue for a care conference, indicating a lapse in the facility's adherence to its care planning schedule. Similarly, Resident 41, admitted in January 2023 with acute respiratory failure and moderate cognitive decline, had not had a documented care conference since January 2024. Although staff mentioned a care conference supposedly took place in June 2024, they were unable to provide documentation or confirm the involvement of the resident's representative. This lack of documentation and involvement highlights a failure in the facility's process for ensuring regular and inclusive care planning for its residents.
Failure to Notify Ombudsman of Resident Hospitalization
Penalty
Summary
The facility failed to notify the Office of the State Long Term Care Ombudsman about the hospitalization of a resident, which is a requirement for ensuring advocacy. This deficiency was identified during an interview and record review, where it was found that there was no documentation indicating that the Ombudsman was informed about the discharge of a resident to an acute care hospital. The resident in question was admitted to the facility in May 2024 with diagnoses including a urinary tract infection and bacteremia. The resident's discharge to the hospital was recorded in the Discharge MDS on May 23, 2024. However, the facility administrator confirmed that the Ombudsman was not notified of the resident's discharge.
Failure to Provide Bed Hold Policy Notice During Hospital Transfers
Penalty
Summary
The facility failed to provide residents with a written notice of the bed hold policy at the time of transfer to a hospital, as required. This deficiency was identified for two residents who were reviewed for hospitalization. Resident 4, admitted in May 2009 with diagnoses including epilepsy and dementia, experienced a change in condition on January 31, 2024, necessitating a transfer to a hospital. Upon review of Resident 4's health record, there was no documentation indicating that a copy of the facility's bed hold policy was provided at the time of transfer. This was confirmed by both the Administrator and the Interim Director of Nursing Services (DNS) on August 15 and 16, 2024, respectively. Similarly, Resident 56, admitted in May 2024 with diagnoses including a urinary tract infection and bacteremia, was transferred to a hospital on May 23, 2024, due to a change in condition. A review of Resident 56's health record also revealed a lack of documentation showing that the bed hold policy was provided at the time of transfer. This omission was confirmed by the same staff members on the same dates. The failure to provide this critical information placed residents at risk of not understanding their choices and potential financial responsibilities during hospital transfers.
Failure to Provide Nail Care Services
Penalty
Summary
The facility failed to provide nail care services to a resident who required assistance with activities of daily living (ADL) due to a stroke resulting in hemiplegia. The resident was admitted in February 2020 and had physician orders from July 2022 for a licensed nurse to check and trim fingernails and toenails weekly. However, from June to August 2024, the Licensed Nurse (LN) Care Records indicated that nail care was marked as not needed on several occasions, and the resident reportedly refused nail trimming on two dates in June 2024. On August 13, 2024, the resident expressed that their nails were too long, nail care had not been offered recently, and they would not have refused if it had been offered. Observation confirmed the resident's nails were extended and dirty, and a staff member acknowledged that the nails had not been trimmed for an extended period.
Delayed Antibiotic Treatment and Medication Error
Penalty
Summary
The facility failed to initiate timely antibiotic treatment and follow physician orders for two residents, leading to unmet needs. Resident 28, admitted with heart failure, diabetes, and a foot ulcer, had a wound culture taken on 6/27/24, which showed infection. However, the results were not communicated to the provider until 7/18/24, delaying the start of antibiotics until that date. Additionally, the facility did not notify the physician of Resident 28's significant weight gains as required by the physician's orders, which occurred on multiple occasions in July and August 2024. Resident 4, admitted with depression, had a medication error when sertraline, prescribed upon hospital readmission on 4/10/23, was not added to the MAR. This oversight led to increased physical and verbal behaviors, as noted in a psychiatric consultant's progress note. The medication was only restarted on 5/6/24, over a year after the initial order. Staff confirmed the medication error, acknowledging the failure to transcribe the order upon readmission.
Inadequate Fall Prevention and Investigation
Penalty
Summary
The facility failed to implement necessary interventions to reduce the risk of falls and did not conduct thorough investigations following falls for two residents. Resident 37, who was admitted with conditions including diabetes and an amputation, was identified as high risk for falls. Despite this, the resident experienced an unwitnessed fall in their room. The care plan, which included measures such as keeping personal items within reach and wearing nonskid footwear, was not followed, and the investigation lacked detailed information about the circumstances of the fall. Staff acknowledged that the investigation was not thorough and that the care plan was inaccurately documented. Similarly, Resident 360, admitted with a urinary tract infection and acute kidney failure, was found on the floor after attempting to go to the bathroom. The investigation into this incident was incomplete, lacking witness statements, as the only witness, a CNA, was not interviewed. Staff acknowledged that the investigation did not provide a complete picture, and the possibility of abuse or neglect could not be ruled out due to the lack of thoroughness in the investigation.
Failure to Follow Physician Orders for Respiratory Care
Penalty
Summary
The facility failed to adhere to physician orders for a resident requiring respiratory care, specifically in the administration of humidity mist via a tracheostomy. The resident, admitted in March 2024 with diagnoses including respiratory failure and malnutrition, had a physician order dated March 13, 2024, specifying the use of humidity mist at a flow rate of eight liters per minute at all times. However, on August 15, 2024, it was observed by a Licensed Practical Nurse (LPN) that the humidity mist was set at four liters per minute, contrary to the physician's order. This discrepancy was confirmed later the same day by the Interim Director of Nursing Services (DNS), who acknowledged that the humidity mist should have been set at eight liters per minute at all times.
Failure to Provide Physical Therapy Services
Penalty
Summary
The facility failed to employ a Physical Therapist to provide necessary therapy services to a resident who was reviewed for therapy services. This deficiency was identified through interviews and record reviews. The resident, who was admitted with multiple left toe fractures, had hospital orders from August 6, 2024, for a physical therapy (PT) evaluation and services. However, from August 6, 2024, to August 13, 2024, the resident had not been evaluated by a PT and consequently did not receive PT services to assist with transfer safety and mobility. On August 14, 2024, the Rehabilitation Director acknowledged the facility's inability to maintain a consistent physical therapist, which led to a reduction in the frequency and duration of therapy services for all residents, including the resident in question.
Lack of Coordination and Documentation of Hospice Services
Penalty
Summary
The facility failed to coordinate and document hospice services for a resident who was admitted with diagnoses including failure to thrive and acute kidney failure. The resident was admitted to hospice services shortly after admission to the facility, but there was no documentation in the resident's health record regarding hospice care, including contact information, physician's orders, hospice care plan, or hospice notes. Interviews with staff revealed a lack of awareness and communication regarding the hospice services being provided to the resident. The Social Services Director was unaware of when hospice care began, and a CNA had not seen any hospice providers or communicated with hospice staff. An RNCM acknowledged the absence of hospice documentation in the resident's health record.
Failure to Address Grievance on Missing Personal Property
Penalty
Summary
The facility failed to follow up on a grievance related to missing personal property for a resident who was admitted in June 2020 with a diagnosis of depression. A public complaint was received in July 2024 regarding the missing items after the resident was discharged in April 2024. The complainant, identified as Witness 1, reported the missing belongings to the facility via phone but did not receive a response. Staff members, including the Social Services Director and the LPN Resident Care Manager, stated they had not received any complaints or grievances from the resident or their representatives about the missing items. The facility's grievance binder showed no record of a grievance from the resident or their representatives. The receptionist acknowledged receiving a call from the complainant about the missing items but could not recall if it was reported to management. The administrator and the grievance officer both stated they had not been informed of the issue. The grievance officer emphasized that all grievances, whether written or verbal, should be reported to her or the administrator, and the administrator confirmed that verbal grievances should be treated with the same importance as written ones.
Inadequate Staffing and Delayed Call Light Response
Penalty
Summary
The facility failed to have adequate staff available to meet resident care needs in a timely manner, resulting in delayed and unmet needs and lengthy call light response times. Observations from 5/9/24 through 5/13/24 revealed multiple instances where call lights were not responded to promptly, with wait times ranging from 25 minutes to over an hour and a half. For example, on 5/9/24, a call light in one room was activated at 11:33 AM and was not responded to until 1:15 PM, resulting in a wait time of one hour and 42 minutes. During this period, the resident's spouse repeatedly sought assistance, and staff were observed walking past the room without responding to the call light. Interviews with staff and residents further highlighted the issue of inadequate staffing. Staff members reported being consistently short-staffed, with high-acuity residents requiring extensive care. One CNA mentioned being assigned several high-acuity residents, making it difficult to provide timely care. Another CNA stated that the facility had been short-staffed since 9/2023, leading to missed showers and increased resident falls. Residents also expressed concerns about long wait times for assistance, particularly around mealtimes when CNAs were occupied with feeding residents who required total assistance. The staffing coordinator admitted to determining CNA staffing based on mandatory minimum ratios without considering resident acuity needs. This lack of communication regarding resident acuity contributed to the ongoing problem of long call light response times. The facility administrator acknowledged the issue but stated that staffing was typically based on mandatory minimum ratios, with an expectation that call lights be responded to within 15 minutes.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 574 citations issued within 25 miles in the last 12 months — including the 4 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.
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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.
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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) |
|---|---|---|---|---|
| Fernhill Rehabilitation And Care | 1.1 mi | ★★★★★ | 0 | 0 |
| Providence Child Center | 1.8 mi | ★★★★★ | 2 | 0 |
| Evergreen Post Acute | 2 mi | ★★★★★ | 3 | 0 |
| Holladay Park Plaza | 2.5 mi | ★★★★★ | 4 | 0 |
| Belmont Care And Rehabilitation | 2.7 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.