Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Portland Health And Rehabilitation during CMS and state inspections, most recent first.
Resident Council Concerns Not Addressed: The facility failed to respond to resident council concerns raised across multiple council meetings. Residents reported they did not feel heard and said they received no response from admin or departments regarding concerns about food quality, spices for meals, personal money access, and laundry return. The Activity Director confirmed there was no communication process for resident concerns, and the Administrator acknowledged the lack of written responses to the council.
A facility failed to have a system for Saturday mail delivery for a Resident Council-reviewed resident group. Residents stated mail was not delivered on Saturdays, and staff gave conflicting accounts about whether the MOD delivered mail, while the Administrator acknowledged there was no other system in place for Saturday delivery.
Unsecured medication carts were observed on multiple halls when carts were left unattended with unlocked drawers or an open drawer, allowing access to residents' prescribed meds, insulin vials, insulin needles, syringes, and glucometers. Staff confirmed the carts were supposed to remain locked when unattended, but the carts were found unlocked or not fully closed while nurses were not in view.
Failure to implement EBP for two residents with chronic pressure ulcers. Staff performed wound care using gloves but no gowns, and one resident’s room had no EBP signage or PPE posted. The IP and DON stated residents with chronic wounds should be in EBP, but EBP was not in place for either resident.
Facility staff failed to complete resident-specific monitoring and follow orders for several residents. One resident’s abuse allegation involving another cognitively impaired resident was not fully assessed or monitored in the record, another resident’s sexual abuse allegation lacked documented follow-up assessments, and a third resident’s room-entry concerns were not specifically monitored. The facility also failed to document ordered zinc oxide administration on the TAR, did not assess a prior shaking/unresponsive episode for a resident with seizures, and did not notify the physician of ordered weight gains for a resident with kidney disease and HF.
Failure to assist residents with advance directives: Two residents lacked proper facility support for advance directive documentation. One resident admitted with esophageal obstruction and dysphagia had no AD on file and said no one offered the opportunity to complete one, while another cognitively intact resident with a pressure ulcer said an AD existed but the facility had not obtained a copy. Staff acknowledged the gaps in the admission and ongoing process.
Failure to assess wedges used as a restraint for a resident with stroke, dementia, and high fall risk. Staff confirmed wedges were used in bed to keep the resident from rolling or falling out, but there was no physician order, documented assessment, informed consent, or care plan intervention addressing their use.
A resident admitted with dementia was started on Risperdal and olanzapine, but the AIMS baseline assessment was not completed when the antipsychotics were initiated. The AIMS was not documented until about three months after admission, and staff acknowledged it was not done timely for baseline assessment.
A resident with seizures became unresponsive with tremors at the nurse's station and was sent to the hospital for eval and tx. The clinical record lacked documentation that a bed hold policy was provided to the resident or the resident's representative, and the RNCM stated she did not notify the representative of the bed hold policy. The Administrator stated residents were not required to pay to hold their bed and could return after hospitalization even without a bed hold notification.
Incomplete Comprehensive Assessments for Psychotropic Medication Use and Pressure Ulcer Care: Two residents had MDS/CAA documentation that failed to fully analyze key clinical issues. One resident with dementia and behavioral disturbances was receiving antipsychotics and an antidepressant, but the CAA did not address the mental health dx, history, or rationale for continued psychotropic use. Another resident with a sacral pressure ulcer and osteomyelitis had an annual MDS/CAA that noted a pressure ulcer and nutrition, but did not analyze the wound, whether it was chronic, or whether it was expected to heal.
Failure to Provide Resident-Centered Activities: A resident with anxiety, post-stroke dysphagia, cognitive impairment, and dependence for all ADLs/mobility had documented interests in music, birds, outdoor time, family calls, sensory visits, and 1:1 visits, but was repeatedly observed in bed with little accessible leisure support. Staff described the resident as mostly liking TV, yet the resident said Western programs were not liked and stated being bored; the AD noted no set schedule for 1:1 visits, no group activity attendance in over a year, and no music or other leisure opportunities in the room.
Pressure ulcer care was not provided as ordered for one resident with osteomyelitis and a pressure ulcer when an RNCM used collagen sheet instead of ordered collagen powder and applied the dressing in a different sequence. For another resident with a coccyx pressure ulcer, weekly skin checks showed the wound remained unchanged for multiple weeks, and staff noted that if there was no change, the physician should assess the wound and provide additional recommendations.
A resident with CKD and a chest fistula ordered for dialysis three times weekly did not have required pre- and post-dialysis assessments completed after dialysis treatments. Records showed no documented dialysis flow sheets or formal checks for multiple treatments, and the resident stated staff did not perform any formal checks after returning from dialysis. An RN and the RNCM confirmed the assessments were not done.
The facility failed to ensure that two residents or their representatives understood a binding arbitration agreement before it was signed. One resident was cognitively intact but stated she/he did not know what the agreement meant and would not have signed it if it waived the right to file a lawsuit. Another resident had moderate cognitive impairment, and the family contact stated he did not know what the agreement meant and had not wanted the resident to sign papers without his knowledge. Staff stated they reviewed arbitration agreements with residents if cognitively intact and involved family when needed.
Undignified Verbal Dispute With Resident: A CNA entered and exited a resident’s room loudly, slammed the door, and then engaged in a verbal dispute with the resident after being confronted about the behavior. The resident, who had hemiplegia, depression, and anxiety but normal cognition, reported feeling hurt by the interaction. A shared-room witness and an LPN both observed shouting and disrespectful back-and-forth, and facility leadership later described the CNA’s conduct as unprofessional and undignified.
Failure to Protect Residents from Abuse: Two separate incidents showed residents were not protected from abuse. In one event, a resident with dementia and epilepsy verbally and physically threatened two other residents during a smoking-break exit, including profanity, threats to kill, and an attempted strike; staff confirmed the aggressive behavior and the DNS concluded abuse occurred. In another event, a cognitively intact resident reported that a resident with severe cognitive impairment entered the room and touched the resident’s thigh and legs in a nonconsensual manner, which the DNS also confirmed.
The facility failed to report allegations of abuse within the required 2-hour timeframe for three residents. The policy required suspected or alleged abuse to be reported immediately, but the FRI was not sent to the SA until later, and the DNS stated he was not aware of any other attempts to contact the SA within the required timeframe. The Administrator confirmed the report was submitted late.
Failure to provide required ADL assistance for two dependent residents. One resident with stroke and dementia had no care plan interventions for facial hair removal and was repeatedly observed with long chin hair despite stating a preference for staff to remove it; staff acknowledged the grooming need. Another resident with fracture and legal blindness was found soiled with feces on the bed, floor, and clothing, and staff interviews confirmed incontinent care was not provided as required by the care plan.
A resident with chronic respiratory failure and CHF, who required one-to-one supervision during meals for aspiration precautions, was found alone with a partially eaten meal and no staff present. The speech therapist confirmed the lack of supervision, and the assigned CNA was unaware of the resident's care plan interventions.
The facility failed to timely assess and address changes in condition for two residents with skin conditions. One resident experienced significant pain and untreated fractures due to delayed response to reports of pain and injury. Another resident had untreated self-inflicted scratches and scabs, which were not reported to the physician or treated as required. The facility did not monitor or document the condition of the wounds, leading to inadequate care.
The facility failed to adequately assess and revise care plans for fall prevention, resulting in multiple incidents involving three residents. One resident, admitted with a history of falls, experienced several falls and was hospitalized, ultimately passing away. Another resident with frequent falls and impaired cognition had multiple non-injury falls, with care plan interventions not consistently followed. A third resident fell out of bed, and temporary safety measures were not implemented while awaiting a perimeter mattress. The facility's failure to implement timely and effective fall prevention measures placed residents at risk for injury.
The facility failed to facilitate Resident Council meetings, as required by their policy, since March 2024. Despite the Activities Director's claim that residents were uninterested, the Resident Council president and other residents expressed a desire for meetings. The Administrator, who started in August 2024, confirmed the absence of meetings, relying on information from the previous DNS without further verification.
The facility failed to provide a qualified Activities Director, impacting residents' needs. The Activities Director, hired with minimal experience, received no training in developing or implementing programs for adults in a nursing facility. She relied on internet resources and lacked guidance on working with residents with dementia or communication difficulties. The Administrator and DNS confirmed the lack of training and were assisting her with activity ideas.
The facility did not complete annual performance reviews for five CNAs, hired between 2017 and 2023, as required. This lapse was confirmed by the Business Office Manager and the Administrator, placing residents at risk of care from potentially incompetent staff.
A facility failed to prevent cross contamination by storing clean laundry items on the soiled side of the laundry room. Staff responsible for housekeeping and laundry confirmed the improper storage, and the Business Office Manager overseeing these departments acknowledged the error. The facility administrator also recognized that clean linens should not have been stored on the dirty side.
The facility failed to ensure accurate assessments for three residents, leading to unmet care needs. A resident with chronic respiratory failure had unaddressed hearing impairments, another was inaccurately assessed as having teeth despite being edentulous, and a third resident was incorrectly coded as needing more assistance with eating than required. Staff confirmed these inaccuracies, and the MDS Coordinator acknowledged errors in the assessments.
A facility failed to conduct a PASARR Level II evaluation for a resident with serious mental illness indicators. Despite a positive Level I PASARR and ongoing behavioral issues, no Level II evaluation was completed. The Social Services Director lacked training on the PASARR process, and the facility administrator admitted the evaluation should have been conducted.
Two residents in a LTC facility were not provided with person-centered activities as required by their care plans. One resident, with cognitive impairments, was not engaged in exercise classes or one-to-one sessions, while another resident, enrolled in hospice care, did not receive personalized activities like listening to music or going outside. The activities director lacked training, and the facility acknowledged the need for improvement.
A resident with a history of pain and contracted fingers on the left hand did not receive timely pain management before wound care treatments, despite physician orders for PRN oxycodone. The resident and a family member reported that pain medication was often administered too late to be effective. Staff interviews revealed inconsistencies in pain management practices, with an LPN failing to offer medication before treatment, contrary to the DNS's expectations.
A resident with bipolar disorder, depression, and panic disorder did not receive necessary behavioral health care services. Despite increased depression and aggression, the facility failed to revise care plan interventions or refer the resident to an in-house psychiatrist. The resident remained isolated and expressed suicidal ideations, with staff acknowledging the inadequacy of interventions and monitoring.
A resident in hospice care experienced delayed pain management due to ineffective communication between the facility and hospice provider. A fentanyl patch order was delayed by several days, and the patch was placed incorrectly on the resident's arm instead of the chest. Family and hospice staff reported ongoing communication issues, and facility staff were unaware of specific care instructions.
A resident, admitted for aftercare following surgical amputation and assessed as cognitively intact, overheard a former hospitality aide using a homophobic slur during a dinner service. The resident felt afraid and uncomfortable, fearing retaliation due to past experiences. Multiple staff members confirmed the incident, although the aide did not recall using the slur. The facility's investigation noted the resident was placed on alert monitoring for psychosocial well-being.
The facility failed to maintain a safe and comfortable environment, as a resident's bed mattress was found to be severely worn, making it difficult for the resident to move. Additionally, offensive odors, particularly of urine, were reported and observed in various areas, including bathrooms and hallways, with cracked tiles and inadequate sealing contributing to the issue. Staff confirmed the need for mattress replacement and repairs to address the odor problem.
A facility failed to ensure the correct POLST was available for a resident with chronic obstructive pulmonary disease, leading to a discrepancy in the resident's code status. The resident had two conflicting POLST documents, one indicating full code and the other DNR. Despite the resident's indication of wanting to be full code, staff confirmed the code status was inaccurately documented as DNR.
Resident Council Concerns Not Addressed
Penalty
Summary
The facility failed to effectively respond to resident council concerns raised during 3 of 3 resident council meetings reviewed for facility response to Resident Council concerns. The facility’s 1/2017 Resident Council Policy stated the facility was expected to communicate a response and/or decisions to the Resident Council by the next meeting, but residents reported during the 2/25/26 Resident Council meeting that they did not feel heard about their concerns or suggestions and stated they did not receive a response from administration or departments regarding the concerns they reported. A review of the Resident Council/Family Council Department minutes showed that on 12/12/25 residents expressed concern about food quality and personal money access, on 1/14/26 residents expressed concern about requested spices for food and laundry return, and on 2/16/26 residents again expressed concern about wanting spices for their food. The minutes reflected that no responses were provided to the Resident Council for these concerns. Staff 23, the Activity Director, confirmed the lack of responses and stated there was not any form of communication for facility departments with resident concerns. Staff 1, the Administrator, acknowledged the lack of response to the Resident Council concerns as a council and stated all Resident Council concerns should be appropriately addressed in written form and given to the Resident Council to review.
Failure to Deliver Resident Mail on Saturdays
Penalty
Summary
The facility failed to have a system in place to deliver mail on Saturdays for 1 of 1 Resident Council reviewed. During the Resident Council group interview, residents stated their mail was not delivered on Saturdays. Staff interviews showed conflicting information about who was responsible for Saturday mail delivery: the Activity Director stated the MOD delivered mail on Saturdays, while an RNCM who sometimes worked as the MOD stated she never delivered mail to residents, and an RN who also worked as the MOD at times stated he never passed mail to residents. The Administrator stated he expected the MOD to deliver mail on Saturdays and acknowledged there was no other system in place to deliver mail to residents on Saturdays.
Unsecured Medication Carts
Penalty
Summary
The facility failed to ensure medications and biologicals were secured and accessible only to authorized personnel for 2 of 3 facility halls observed for secure medication cart. On one hall, an unattended medication storage cart was observed with unlocked drawers while two staff members and a visitor walked past it. Staff later confirmed the drawer had been left unlocked and unattended while the nurse was in a resident room, and the cart contained residents' prescribed medications, insulin vials, and insulin needles. On another observation, a medication storage cart was found with an opened drawer while unattended, allowing access to the contents of the drawer. The drawer contained insulin vials and insulin needles, and two staff members walked by without taking action. A nurse later confirmed the drawer had not been fully closed and was therefore left unlocked while unattended, and stated the cart contained insulin vials, syringes, and glucometers. A third observation on the North Hall found a medication cart unlocked and unattended, and an LPN confirmed it had been left that way.
Failure to Implement Enhance Barrier Precautions for Residents With Chronic Wounds
Penalty
Summary
The facility failed to implement Enhance Barrier Precautions for two residents with chronic pressure ulcers. One resident was admitted with a diagnosis of pressure ulcer and had a left buttock pressure ulcer first observed on 3/27/25; during wound care on 2/25/26, Staff 4 performed hand hygiene and donned gloves, but did not wear a gown, and stated a gown was not needed. The ulcer was observed to have no signs of infection. Staff 8, the Infection Preventionist, stated on 2/26/26 and 2/27/26 that residents with chronic wounds that did not have significant drainage were on standard precautions, but also stated that residents with chronic wounds should be on EBP and that this resident did not have EBP in place. Staff 2, the DNS, also stated that residents with chronic wounds should be in EBP. A second resident was admitted with a diagnosis of pressure ulcer and had an annual MDS showing cognitive intactness. On 2/23/26 and 2/25/26, the resident’s room had no signage and no PPE by the door to indicate EBP. The resident stated staff did not use gowns when performing wound care and declined observation of wound care. Staff 4 stated she did not wear a gown when performing wound care for this resident. Staff 8 again stated that residents with chronic wounds should be on EBP but that this resident did not have EBP in place, and Staff 2 stated that residents with chronic wounds should be in EBP.
Failure to monitor residents and follow physician orders
Penalty
Summary
The facility failed to monitor residents and follow physician orders for six sampled residents related to abuse allegations, supervision needs, medication administration, change in condition, and weight monitoring. Resident 37, admitted with a spinal fracture and severe memory impairment, alleged that a resident of the opposite sex entered the room and touched the chest and abdominal area. The investigation identified Resident 68 as the alleged perpetrator, but the facility could not corroborate Resident 37’s allegation. The record showed no documented assessment of Resident 37’s psychosocial status after the allegation, and no documented monitoring specific to the concern beyond general notes. Resident 68, who had facial fractures and severe cognitive impairment, also had no documented assessment to ensure monitoring to prevent entry into other residents’ rooms. Resident 48, who was cognitively intact and had a pressure ulcer diagnosis, alleged that Resident 68 entered the room and touched the thigh without consent. The facility placed Resident 48 on 1:1 supervision and alert charting, but the record did not show a documented assessment on one of the days following the allegation, and later notes did not specifically address the abuse concern. Resident 55 had an order for zinc oxide to be applied every two hours, but the January and February TARs did not include the order, and the DNS acknowledged the order was not on the current TARs and was not documented as administered. Resident 62, admitted with seizures, was documented as shaking and unresponsive, with a CNA stating the resident had done this again the day before, but the record did not contain an assessment of the earlier event. Resident 63, admitted with kidney disease and heart failure, had physician discharge orders for daily weights and notification if weight increased by three pounds in 24 hours or five pounds in five days. The weight log showed multiple gains, including a 7.4-pound increase and other increases that met the notification threshold, but the record did not show the physician was notified on the dates identified. The DNS stated the resident was on dialysis and weight fluctuations were expected, but staff did not call the physician with the ordered weight gains and should have clarified the order due to dialysis-related fluctuations.
Failure to Assist Residents With Advance Directives
Penalty
Summary
The facility failed to assist residents in formulating and obtaining advance directives for 2 of 3 sampled residents reviewed for advance directives. Resident 26 was admitted in 1/2026 with diagnoses of esophageal obstruction and dysphagia. The clinical record contained no documentation of an advance directive and no evidence that the resident was provided written information about the right to formulate one. During interview, Resident 26 stated that an advance directive had not been completed and that the resident had not been offered the opportunity to formulate one. Staff 5, the Business Office Manager/Human Resources, stated that residents without an advance directive were offered a blank advance directive during their initial care conference, and confirmed Resident 26 had not been offered the opportunity to complete one. Resident 48 was admitted in 1/2025 with a diagnosis of pressure ulcer, and the 1/13/26 Annual MDS indicated the resident was cognitively intact. The care plan stated the resident did not have an advance directive and that staff were to offer advance directive information at least quarterly. During interview, Resident 48 stated having an advance directive, but Staff 5 stated the facility had not obtained a copy. The Administrator stated it was the facility's responsibility to ensure residents were informed of their right to formulate an advance directive upon admission and that the process should be completed in accordance with required guidelines.
Failure to Assess Wedges Used to Prevent a Resident From Falling Out of Bed
Penalty
Summary
The facility failed to assess the use of a physical restraint for one resident who had diagnoses of stroke and dementia and was identified as high risk for falls. The resident’s annual MDS indicated no physical restraints were in place, and a Morse Fall Scale assessment showed a history of falls and impaired balance while standing. The care plan addressed impaired mobility and fall risk with interventions such as placing the bed against the wall, keeping the bed low, monitoring for seizure activity, and placing a mattress on the floor next to the bed, but it did not include the wedges that were being used in the resident’s bed. During observation, a sign above the bed instructed staff to ensure a body pillow was in place before leaving the room to protect the resident from falling out of bed, and two wedges were observed propped against the wall in the room. Staff stated the devices used were wedges, not a body pillow, and that they were used each time the resident was in bed or at night to prevent the resident from rolling or falling out of bed. Record review and staff interviews confirmed there was no physician order, documented assessment, evaluation for potential restraint use, informed consent, or care plan intervention addressing the wedges.
Delayed Baseline AIMS Assessment for Resident on Antipsychotic Medications
Penalty
Summary
The facility failed to obtain a baseline assessment for one resident who was admitted with a diagnosis of dementia and was started on Risperdal and olanzapine. The resident’s clinical record showed that an AIMS assessment was not completed until three months after admission and after antipsychotic therapy had already been initiated. During observation, the resident was seen without abnormal involuntary movements. Staff stated that an AIMS should be completed when a resident is first started on an antipsychotic medication and then every six months, and the DNS acknowledged that the resident’s AIMS was not completed timely for baseline assessment.
Failure to Provide Bed Hold Policy After Hospital Transfer
Penalty
Summary
The facility failed to provide a bed hold policy for 1 of 1 sampled resident reviewed for hospitalization. Resident 62 was admitted with a diagnosis of seizures and, according to the 1/26/26 progress note, was observed sitting at the nurse's station, had tremors, and was unresponsive before being transported to the hospital for evaluation and treatment. The resident's clinical record did not contain documentation showing that a bed hold policy was provided to the resident or the resident's representative. During interview, the RNCM stated the resident was not stable when transported to the hospital and that she did not notify the resident's representative of the bed hold policy. The Administrator stated the facility residents were not required to pay to hold their bed and that all residents were allowed to return from hospitalization even without a bed hold notification.
Incomplete Comprehensive Assessments for Psychotropic Medication Use and Pressure Ulcer Care
Penalty
Summary
The facility failed to complete a comprehensive assessment for 2 of 7 sampled residents reviewed for pressure ulcer and unnecessary medications. For Resident 2, who was admitted with a diagnosis of dementia with behavioral disturbances, the 11/2025 MAR showed administration of olanzapine for delusions, risperidone for delusions, and sertraline for mood disorder. The resident’s 11/18/25 admission MDS and associated CAA identified psychotropic medication use, but there was no analysis of the resident’s medical condition, history, or rationale for continued use of the psychotropic medications. Staff 16, the MDS Coordinator, verified that the admission MDS did not address the resident’s mental health diagnosis, history, psychotropic medications, or the goal of treatment, and Staff 2, the DNS, stated the CAAs should have included an analysis of the psychotropic medication use. For Resident 48, who was admitted with a diagnosis of pressure ulcer, the 1/28/25 hospital discharge summary documented a sacral pressure ulcer with tunneling and osteomyelitis, and the resident was discharged to the facility for wound care. The 1/13/26 annual MDS and CAAs identified a pressure ulcer, and the analysis included nutrition information, but there was no information about the pressure ulcer itself, whether it was chronic, or whether it was expected to heal. Staff 16 verified that the annual MDS and CAAs did not address the resident’s pressure ulcer or refer to documentation supporting the rationale for the care plan and treatment goal, and Staff 2 stated the CAAs should have included an analysis of the resident’s care related to the pressure ulcer.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide resident-centered activities for a resident who was admitted in 2019 with diagnoses including anxiety and dysphagia following cerebral infarction. The 9/25/25 Annual MDS showed the resident was cognitively impaired, speech was unclear and rarely understood, and the resident was dependent on staff for all ADL and mobility needs. The resident’s documented interests included watching television, sitting in the lobby, listening to music, and individualized visits, and the 10/25/25 Activity Quarterly Progress Note also identified interests in music, going outside for fresh air, watching birds and the bird feeder outside the room window, making phone calls to family, sensory visits, and one-to-one individualized visits. During observations in February 2026, the resident was repeatedly found in bed with limited or no accessible leisure opportunities in the room. The television was observed playing a Western program that the resident could not hear or did not want to watch, the room had no music devices or visible leisure supplies, and no family pictures or room decorations were visible at one point. The resident stated that the Western programs were not liked and that the resident was bored. Staff stated the resident mostly liked to watch television and did not share other activities or leisure interests, while the Activity Director stated there was no set schedule for one-to-one visits and acknowledged the resident had not attended group activities in over a year and had no music or other leisure opportunities in the room. The Kardex listed preferred activities including one-to-one visits, art, music, animals, movies, and the outdoors, and the record of one-to-one activities showed limited sessions such as reading, bird watching, and listening to music.
Pressure ulcer care and wound orders not followed
Penalty
Summary
Pressure ulcer care was not provided as ordered for Resident 11, who was admitted with osteomyelitis and a pressure ulcer. The 2/3/26 order directed the wound to be cleaned with wound cleanser, one gram of collagen powder to be applied to the wound bed, a calcium alginate sheet to be lightly packed, and the wound to be covered with a border dressing. During observation on 2/25/26, Staff 4 cleaned the ulcer, dried it, applied a collagen sheet instead of the ordered powder, placed calcium alginate on top of the collagen sheet, and covered it with a border dressing. Staff 4 later stated the facility had both powder and sheets of collagen and acknowledged using the sheet rather than the powder, while Staff 2 stated that if orders needed to be changed, the physician was to be notified. Resident 48 was admitted with a diagnosis of pressure ulcer, and the coccyx wound care orders were last updated on 12/23/26. Weekly skin evaluations showed the coccyx wound improved on 1/6/26 and 1/13/26, then remained unchanged on 1/20/26, 1/27/26, 2/3/26, 2/10/26, 2/17/26, and 2/24/26. Resident 48 declined wound care observation on 2/25/26. Staff 3 stated pressure ulcers were monitored weekly, Staff 10 stated standard practice was to change treatment if the ulcer did not improve over a two-week period, and Staff 2 stated that if there was no change staff should ask for a physician to assess the wound and provide additional recommendations if needed.
Failure to Complete Dialysis Assessments
Penalty
Summary
The facility failed to perform pre- and post-dialysis assessments for Resident 3, who was admitted with chronic kidney disease and had physician orders for dialysis three times a week through a chest fistula. The facility’s dialysis policy stated that it provides ongoing monitoring of the dialysis access site and uses a Dialysis Flow Sheet to document resident-specific dialysis care, including monitoring of the catheter and fistula. Review of records showed Resident 3 received dialysis on 1/28/26, 2/9/26, and 2/18/26, but no pre- or post-dialysis assessments were found for those dates. Resident 3 stated staff did not perform any formal checks after returning from dialysis, and an RN and the RNCM confirmed that the required pre- and post-dialysis assessments had not been completed.
Failure to Ensure Understanding of Arbitration Agreements
Penalty
Summary
The facility failed to ensure that a resident or representative understood a binding arbitration agreement before signing for 2 of 3 sampled residents. Resident 3 was admitted with kidney disease and had a State Arbitration Agreement form signed on 1/29/26. The resident’s admission MDS dated 2/3/26 showed the resident was cognitively intact, but during an interview on 2/25/26 the resident stated being very sick at admission and not recalling all events, did not know what an arbitration agreement meant, and said the agreement would not have been signed if it had been understood to waive the right to file a lawsuit. Resident 21 was admitted with heart failure and had an emergency contact listed as Witness 1, a family member. The admission MDS dated 1/30/26 showed the resident was moderately cognitively impaired. During an interview on 2/25/26, the resident stated not signing admission paperwork and that Witness 1 may have signed the arbitration agreement. Witness 1 stated the facility had been told the resident was not to sign any papers without his knowledge and said he did not know what an arbitration agreement meant, adding that he would not have allowed the resident to sign if it waived the right to file a lawsuit. Staff stated they reviewed arbitration agreements with residents if cognitively intact and involved family when needed, and acknowledged Resident 21 signed the agreement despite moderate cognitive impairment.
Undignified Verbal Dispute With Resident
Penalty
Summary
The facility failed to ensure care was provided in a manner that maintained Resident 67’s dignity during an interaction with Staff 22, a CNA. Resident 67 was admitted in 6/2024 with diagnoses including hemiplegia, depression, and anxiety, and an 8/14/25 MDS assessment determined the resident had normal cognitive function. According to the facility investigation, Resident 39, who shared a room with Resident 67, witnessed Staff 22 enter and exit the room loudly, and stated that when Staff 22 was confronted about slamming the door, both Staff 22 and Resident 67 raised their voices and Resident 67 became upset. Resident 67 stated Staff 22 was moving quickly around the room and slammed the door on exit, and when Resident 67 asked why the door was slammed, Staff 22 responded, "What are you going to do about it?" Staff 12, an LPN, stated he observed Staff 22 and Resident 67 cursing at each other in the room and later at the nurse’s station while Resident 67 was completing a grievance form. Staff 22 stated Resident 67 was speaking with attitude and cursing about the door, and Staff 22 responded in a confrontational manner, including telling Resident 67, "do what you want" and stating, "I'm not working with disrespectful residents like [her/him] no more." The incident report concluded the event was a verbal dispute provoked by both Resident 67 and Staff 22, and later interviews confirmed Staff 22’s behavior was unprofessional and undignified.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure residents were free from abuse for 3 of 7 sampled residents reviewed for abuse. The facility’s policy stated residents have the right to be free from abuse, including verbal, physical, and sexual abuse, and defined abuse to include the willful infliction of intimidation resulting in mental anguish. One incident involved Resident 6, who had epilepsy and dementia, along with Resident 65, who had a stroke and depression, and Resident 66, who had heart failure and depression. During an attempted exit for a smoking break, Resident 6 believed Resident 65 bumped the wheelchair, leading to a confrontation in which Resident 6 stated Resident 65 yelled at her/him, Resident 6 yelled back with profanity, and Resident 6 threatened to kill Resident 65 if touched again. Resident 65 stated Resident 6 called her/him a profane name and tried to hit her/him, and Resident 66 stated Resident 6 swung at Resident 65, called Resident 65 a profane name, and then verbally threatened Resident 66, causing fear. Staff 11 recalled Resident 6 being aggressive and motioning as if to hit Resident 65, and the DNS confirmed the investigation concluded Resident 6 verbally and physically threatened Resident 65 and verbally threatened Resident 66. A second incident involved Resident 48, who was cognitively intact, and Resident 68, who had severe cognitive impairment. The facility’s investigation documented that Staff 27 heard Resident 48 call out and found Resident 68 in Resident 48’s room. Resident 48 reported that Resident 68 touched her/his thigh inappropriately, while Resident 68 denied the interaction. Resident 68 was removed from the room and placed on 1:1 supervision. Later, Resident 48 stated Resident 68 came into the room and rubbed hands on Resident 48’s legs, and Staff 3 stated Resident 68 was usually at the nurse’s station and not going into other residents’ rooms. The DNS stated Resident 68 touched Resident 48 in a nonconsensual manner.
Late Reporting of Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse within the required timeframe for 3 of 4 sampled residents, involving Residents 6, 65, and 66, in 1 of 5 FRI reports reviewed for abuse. The facility’s revised 2022 policy required all suspected or alleged abuse to be reported immediately, defined as as soon as possible but no later than two hours after the allegation was made. The state agency received the FRI on 9/26/25 at 11:09 AM for an alleged abuse that occurred on 9/25/25 at 9:00 AM involving the three residents. The DNS stated he completed and sent the FRI on 9/26/25 and was not aware of any other attempts to contact the state agency within the required two-hour timeframe. The Administrator confirmed the FRI was submitted late and stated he expected all allegations of abuse to be reported within the required two-hour reporting timeframe.
Failure to Provide Required ADL Assistance
Penalty
Summary
The facility failed to ensure dependent residents received required assistance with ADL care for 2 of 2 sampled residents reviewed for ADL care, placing residents at risk for lack of personal hygiene. One resident, admitted with diagnoses of stroke and dementia, had an annual MDS indicating dependence on staff for personal hygiene and grooming. The care plan dated 1/19/26 had no interventions addressing facial hair removal or grooming preferences. The resident was observed on 2/24/26 and 2/25/26 with a significant amount of visible chin hair, and stated a desire for staff to take care of unwanted facial hair. Multiple staff members observed the long chin hair and acknowledged it needed to be shaved, while an RN and the DNS confirmed there were no care plan interventions for facial hair and that the resident had not received proper ADL care. A second resident, admitted with diagnoses of fracture and legal blindness, had an annual MDS indicating dependence on staff for toileting and hygiene, and a care plan requiring assistance with toilet transfers, setup, and clean-up. A Facility Reported Incident documented that on 8/31/25 morning staff found the resident soiled with a bowel movement, with the brief and bed linens saturated with fecal matter and the floor around the bed soiled. Staff interviews confirmed the resident was found with feces on the bed, floor, sleepwear, and one leg, and that the resident appeared to have been left soiled for an extended period of time. The DNS acknowledged the incident and stated the expectation was that residents needing ADL assistance receive care consistent with their individualized care plans; a former CNA stated he was unaware the resident was incontinent and did not provide incontinent care during the shift.
Failure to Provide Required Supervision for Aspiration Precautions
Penalty
Summary
The facility failed to implement care plan interventions for aspiration precautions for a resident with chronic respiratory failure and congestive heart failure. The resident's care plan required one-to-one supervision during all meals due to aspiration risk. On one occasion, the resident was found alone in their room with a partially eaten meal tray and no staff present, despite calling out for assistance. The speech therapist later confirmed the resident should have been under one-to-one supervision while eating and observed the meal tray unattended. The assigned CNA was unaware of the resident's need for supervised eating and stated it was their first shift working with the resident. The RCM also confirmed the resident's requirement for aspiration precautions and one-to-one supervision during meals.
Failure to Timely Address Changes in Condition and Skin Issues
Penalty
Summary
The facility failed to timely assess and address changes in condition for two residents with skin conditions, leading to significant pain and untreated injuries. Resident 8, who had a history of hemiplegia and hemiparesis following a stroke, experienced increased pain in the right knee and ankle, which was not promptly addressed. Despite multiple reports of pain and a confirmed diagnosis of fractures in the distal fibula and medial malleolus, there was a delay in providing adequate pain relief and in arranging for hospital evaluation. The resident reported significant pain and confirmed the injury occurred during a transfer, yet the facility did not act swiftly to address the resident's condition. Additionally, Resident 8's care plan required staff to monitor for changes in skin integrity, but a blackened toe was not reported in a timely manner. A CNA observed a red blister on the resident's toe but failed to report it immediately, leading to a delay in assessment and treatment. The facility's investigation acknowledged the failure to identify and address the skin issue promptly. Resident 22, admitted with a history of stroke, had multiple self-inflicted scratches and scabs on the upper extremities that were not evaluated or treated as per physician's orders. Despite observations by staff and complaints from the resident, the wounds were not reported to the physician or NP, and no treatment was implemented. The facility failed to monitor and document the condition of the wounds, resulting in a lack of appropriate care and intervention.
Inadequate Fall Prevention and Care Plan Revisions
Penalty
Summary
The facility failed to adequately assess and revise care plans for fall prevention, resulting in multiple incidents involving three residents. Resident 108, admitted with a history of falls and requiring supervision, experienced several falls within the facility. Despite being identified as high risk for falls, the care plan was not effectively revised following each incident. The investigations into these falls were delayed and incomplete, failing to identify and mitigate potential hazards. This lack of timely intervention and supervision led to Resident 108's hospitalization and subsequent death. Resident 40, with a history of frequent falls and impaired cognition, experienced multiple non-injury falls over several months. Although identified as high risk, the facility did not consistently implement or revise fall prevention strategies. Observations revealed that care plan interventions, such as keeping the wheelchair out of sight and engaging the resident in activities, were not consistently followed. Staff acknowledged the need for more thorough root cause analysis and intervention to prevent further falls. Resident 48, admitted with a traumatic subdural hemorrhage, fell out of bed, prompting the need for a perimeter mattress. However, temporary safety measures were not care planned or implemented while awaiting the mattress. Staff were unaware of the resident's fall risk status and recent incidents, indicating a lack of communication and adherence to care plans. The facility's failure to implement timely and effective fall prevention measures placed residents at risk for injury.
Failure to Facilitate Resident Council Meetings
Penalty
Summary
The facility failed to ensure that residents were provided with the opportunity to organize and participate in the Resident Council, as required by their policy. The policy, dated May 2002, stated that the Resident Council was intended to promote resident interest and involvement in the facility and serve as a forum for residents to voice concerns and suggest changes. The council was supposed to meet monthly or at a frequency determined by the council members. However, a review of the facility's Resident Council Minutes revealed that the last meeting occurred in March 2024, despite the facility having a census of 55 residents as of October 2024. Interviews with staff and residents indicated a lack of initiative to continue the Resident Council meetings. The Activities Director, hired in May 2024, stated that meetings did not occur because residents were not interested. However, the Resident Council president and other residents expressed a desire to have meetings, but none had been organized since the previous Activities Director left. The facility's Administrator, who started in August 2024, confirmed the absence of meetings and mentioned that he was informed by the previous Director of Nursing Services that residents were not interested, which he accepted without further verification.
Unqualified Activities Director Leads to Deficiency
Penalty
Summary
The facility failed to provide a qualified professional to direct the activities program, which affected the residents' physical, mental, and psychosocial needs. The facility's Key Personnel list identified Staff 14 as the Activities Director, who was hired in May 2024. Staff 14 admitted to having minimal experience and no training in developing or implementing an activities program for adults in a nursing facility. She relied on internet resources to develop the program and did not receive training on working with residents with dementia or communication difficulties. The previous administrator was supposed to enroll her in an activity training course, but this did not occur. The facility's Administrator and DNS confirmed that Staff 14 did not receive the necessary training and were assisting her with activity ideas until she could be trained.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to conduct annual performance reviews for five Certified Nursing Assistants (CNAs), which is a requirement to ensure competent staffing. Personnel records revealed that CNAs hired on various dates, ranging from 2017 to 2023, did not receive their mandatory annual performance evaluations. This oversight was confirmed by the Business Office Manager and the Administrator, who acknowledged that the expected annual reviews were not completed for these staff members. The lack of performance evaluations placed residents at risk of receiving care from potentially incompetent staff.
Improper Laundry Storage Leading to Cross Contamination Risk
Penalty
Summary
The facility failed to properly store laundry to prevent cross contamination, as observed during a tour of the laundry room. A metal rack containing clean towels, fabric room divider curtains, and sheets was found on the soiled side of the laundry room, covered partially by a cloth sheet held with metal binder clips, leaving the top uncovered. Staff 26, responsible for housekeeping and laundry, confirmed that these items were new and clean but acknowledged that they were improperly stored on the soiled side. This improper storage was confirmed by Staff 11, the Business Office Manager overseeing housekeeping and laundry, who recognized that clean items should not be stored on the soiled side. The facility administrator also acknowledged the error, stating that the clean linens should not have been stored on the dirty side.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure accurate assessments for three residents, leading to unmet care needs. Resident 14, admitted with chronic respiratory failure, was found to have impaired hearing that was not accurately captured in the MDS assessment. Despite being cognitively intact, Resident 14 struggled to hear staff and other residents, and there were no interventions in place to address this issue. Staff members confirmed the resident's hearing difficulties, and the MDS Coordinator acknowledged the oversight in the assessment. Resident 45, admitted with gram-negative sepsis, was inaccurately assessed as having teeth, despite being edentulous. The resident reported not being assessed for swallowing and expressed dissatisfaction with the soft food provided, as they were accustomed to eating regular food at home. Staff confirmed the resident's edentulous status, and the MDS Coordinator admitted to a coding error. Additionally, Resident 22, who had a stroke, was inaccurately coded as requiring supervision or touch assistance with eating, whereas they only needed set-up assistance. Staff confirmed the resident's ability to eat independently after receiving set-up help, highlighting the inaccuracies in the MDS assessment.
Failure to Complete PASARR Level II Evaluation
Penalty
Summary
The facility failed to complete a PASARR Level II evaluation for a resident who had a positive Level I PASARR indicating serious mental illness. The resident, admitted in November 2022, had diagnoses including bipolar disorder, depression, and panic disorder. The initial PASARR Level I conducted on November 9, 2022, identified indicators of serious mental illness, but no Level II evaluation was completed. The resident's condition included increased depression and behaviors such as verbal and physical aggression, swearing, and resisting care, as noted in subsequent evaluations and care plans. Despite these indicators, a second PASARR Level I conducted on March 15, 2023, after a hospitalization, did not identify serious mental illness, and its accuracy was not verified. The resident's family member reported requesting a mental health evaluation multiple times without success. The Social Services Director admitted to lacking formal training on the PASARR process and was unaware of any actions taken following the initial Level I screen. The facility administrator acknowledged that a Level II evaluation should have been conducted following the initial screen.
Failure to Provide Person-Centered Activities
Penalty
Summary
The facility failed to provide an ongoing person-centered activity program for two residents, leading to a deficiency in meeting their psychosocial needs. Resident 40, who was readmitted with diagnoses including diabetes and metabolic encephalopathy, had a care plan that emphasized the need for activities such as exercise classes and one-to-one sessions. Despite these requirements, observations and staff interviews revealed that Resident 40 was not engaged in group or one-to-one activities, and the activities director admitted to a lack of training and experience in developing suitable programs for the resident. Similarly, Resident 48, who was admitted with a traumatic subdural hemorrhage and was enrolled in hospice care, expressed preferences for activities like watching television, listening to music, and going outside. However, the resident's activity logs showed no participation in group activities or one-to-one visits. Staff interviews indicated a lack of awareness of the resident's interests, and the activities director confirmed that no personalized activities were offered to Resident 48. The deficiency was further highlighted by the activities director's acknowledgment of not having developed enhanced activity programs for the residents and the administrator's admission of the need for improvement in this area. The lack of personalized activities for both residents placed them at risk of a decline in psychosocial well-being and diminished quality of life.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide appropriate and timely pain management for a resident with a history of right upper quadrant pain, low back pain, and arthritis. The resident was observed to have contracted fingers on the left hand, which were painful to move. Despite physician orders directing the administration of PRN oxycodone 30 minutes to an hour before wound care treatment, the resident reported that pain medication was often given just prior to or even after the treatment, which did not allow sufficient time for the medication to take effect. This was corroborated by a family member who expressed concerns about the timing of pain medication administration. Staff interviews revealed inconsistencies in pain management practices. A CNA acknowledged the resident's complaints of pain and took care when assisting with personal care. However, an LPN stated that she did not offer pain medication prior to treatment because the resident did not complain about pain. During an observation, the resident expressed distress and demanded pain medication before treatment. The DNS stated that nurses were expected to assess the resident's pain level and offer medication before treatments, indicating a failure to adhere to these expectations.
Failure to Address Behavioral Health Needs
Penalty
Summary
The facility failed to provide necessary behavioral health care services for a resident with a history of bipolar disorder, depression, and panic disorder. The resident, admitted in November 2022, exhibited increased depression and difficulty coping with stress, as noted in multiple evaluations. Despite being on risperdal for bipolar disorder, the resident's care plan interventions were not effectively reviewed or revised to address ongoing mood symptoms and behaviors. Observations and interviews revealed that the resident remained isolated in their room, did not participate in activities, and expressed unhappiness. Family members reported the resident's suicidal ideations to the facility, but no mental health evaluation was conducted. Staff members described the resident as verbally and physically aggressive, with no recent onset of these behaviors. The Social Services Director acknowledged the inadequacy of the behavior monitor in tracking mood symptoms and the lack of appropriate interventions for the resident's depression. The facility's failure to refer the resident to an in-house psychiatrist and the ineffective interventions in place contributed to the deficiency. Staff members, including the Social Services Director and LPN Resident Care Manager, recognized the resident's unhappiness and care refusals but did not take sufficient action to address these issues. The facility administrator confirmed that the resident's mood and behavioral needs were not fully addressed, highlighting a significant gap in the provision of necessary behavioral health care services.
Communication Breakdown with Hospice Leads to Delayed Pain Management
Penalty
Summary
The facility failed to establish an effective communication process with the hospice provider, resulting in unmet needs for a resident receiving hospice care. The hospice policy required a coordinated Plan of Care (POC) between the facility and hospice, with the hospice responsible for notifying the facility of changes in care. However, there was a delay in implementing a physician's order for a fentanyl patch, which was intended to manage the resident's pain. The order was given on October 1, 2024, but the patch was not applied until October 5, 2024. Additionally, the patch was placed on the resident's arm instead of the upper chest as directed, and this issue persisted despite communication from the hospice nurse. The resident, who was admitted with a traumatic subdural hemorrhage and was cognitively intact, experienced pain and was enrolled in hospice care. Observations revealed that the fentanyl patch was consistently placed on the resident's arm, contrary to the hospice's instructions. Family members and hospice staff reported communication issues and delays in implementing hospice orders. Staff members were unaware of the specific instructions regarding the placement of the fentanyl patch, indicating a breakdown in communication and adherence to the hospice care plan.
Resident Dignity Compromised by Staff's Use of Homophobic Slur
Penalty
Summary
The facility failed to ensure a resident was treated in a dignified manner and free from derogatory slurs. This deficiency involved a resident who was admitted in June 2023 with diagnoses including aftercare for surgical amputation and was assessed as cognitively intact. During a dinner service, the resident overheard a former hospitality aide using a homophobic slur in conversation with other staff members. The resident reported feeling afraid and uncomfortable at the facility due to this incident and expressed concerns about potential retaliation, having experienced similar issues in the past. The facility's investigation revealed that multiple staff members confirmed the use of the derogatory term by the former hospitality aide. The resident was placed on alert monitoring for psychosocial well-being following the incident, with no negative outcomes reported. Interviews with staff and the resident confirmed the occurrence of the event, although the former hospitality aide did not recall using the specific slur. The facility administrator stated an expectation for all residents to be treated with dignity and respect, free from homophobic slurs.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to ensure a safe and comfortable environment for its residents, as evidenced by the condition of a resident's bed mattress and the presence of offensive odors throughout the facility. A resident, admitted in 2010 with diagnoses including abnormal posture, cognitive deficits, and depression, was observed to have a bed mattress with a large divot covering approximately three-quarters of the mattress, making it difficult for the resident to move. Staff members, including CNAs and the Maintenance Director, confirmed the mattress was old, broken down, and needed replacement. Additionally, the facility was reported to have offensive odors, particularly of urine, in various areas, including residents' bathrooms and hallways. Complaints were received by the State agency regarding the cleanliness and odor issues. Observations confirmed the presence of strong urine smells in specific rooms and hallways, with cracked tiles and inadequate sealing around toilets contributing to the problem. Despite housekeeping efforts, the Maintenance Director and Administrator acknowledged the persistent odor issues and the need for repairs to address the cracked tiles and sealing problems.
Discrepancy in Resident's POLST and Code Status
Penalty
Summary
The facility failed to ensure the correct Physician Orders for Life-Sustaining Treatment (POLST) was readily available and accessible for a resident, leading to a discrepancy in the resident's code status. The resident, admitted in October 2023 with chronic obstructive pulmonary disease and cognitively intact, had two signed POLST documents with conflicting instructions. The POLST dated October 4, 2023, indicated the resident wished to be full code, while the POLST dated October 27, 2023, indicated a Do Not Resuscitate (DNR) status. A public complaint in June 2024 alleged the resident wanted to be full code, but the POLST was filled out incorrectly. Interviews with staff confirmed the resident's code status was documented as DNR, which was not accurate according to the resident's wishes. The discrepancy was confirmed by the Director of Nursing Services (DNS) on October 29, 2024.
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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) |
|---|---|---|---|---|
| Menlo Park Post Acute | 0.6 mi | ★★★★★ | 15 | 0 |
| Gateway Care And Retirement | 1 mi | ★★★★★ | 0 | 0 |
| Marquis Mill Park | 1.1 mi | ★★★★★ | 13 | 0 |
| Glisan Post Acute | 1.1 mi | ★★★★★ | 11 | 0 |
| Rose City Nursing And Rehabilitation | 1.1 mi | ★★★★★ | 1 | 0 |
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