Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Secora Rehabilitation Of Cascadia during CMS and state inspections, most recent first.
A resident and the resident's attorney made multiple requests for access to the resident's medical records, including billing and care documentation. The facility only partially fulfilled these requests, with significant delays and incomplete responses, despite repeated follow-ups. The resident did not receive the requested records within the required timeframe, and staff acknowledged the failure to provide timely access.
The facility failed to maintain the required dishwasher temperatures, risking un-sanitized dishware and potential communicable diseases. Observations showed water temperatures consistently below the required 120 degrees F, with trays washed at 90 degrees F and plates at 110 degrees F. The Dietary Manager confirmed the deficiency.
The facility failed to ensure two residents were fully informed about the binding arbitration agreement. One resident's legal representative was unaware of the correct rescission period, while another resident with impaired cognition did not recall consenting to the agreement. The facility's arbitration agreement inaccurately stated the rescission timeframe, confirmed by the Administrator-In-Training.
The facility did not ensure that CNA staff received the mandated 12 hours of annual in-service training. Two CNAs were found to have completed only 7.5 and 1.5 hours of training, respectively. This was confirmed by the Administrator-In-Training and the Clinical Resource, highlighting a failure to adhere to the facility's policy on maintaining staff competence and knowledge.
A resident with vascular dementia and a history of stroke did not receive their prescribed anticoagulant, Rivaroxaban, for three consecutive days. This oversight led to the resident developing stroke-like symptoms and being sent to the hospital. The LPN responsible did not follow protocol by failing to notify staff or the provider about the missed doses.
A resident with major depressive disorder was found with medications on their nightstand without a completed self-administration assessment, contrary to facility policy. Staff confirmed that medications should not be left at the bedside without an assessment, highlighting a failure to ensure safe medication practices.
A facility failed to assist a resident in formulating an advance directive, despite the resident's request for help. The resident, admitted with pneumonia and anxiety, expressed a desire for assistance, but no advance directive was on file. The Social Services Director discussed the matter with the resident, but no follow-up occurred, as confirmed by the facility administrator.
A facility failed to provide adequate showers for a resident with moderate cognitive impairment and incontinence, compromising personal hygiene and dignity. Despite being scheduled for showers twice a week, the resident received them inconsistently, with significant gaps between showers. Staff confirmed that missed showers were not rescheduled due to time constraints, and the DNS acknowledged the failure to meet the facility's policy of providing at least two showers per week.
A facility failed to implement an activity care plan for a non-verbal resident with cerebral palsy, leading to isolation and lack of engagement. The resident was not invited to group activities and was often found lying in bed without access to preferred activities like music or audio books. Staff interviews revealed a lack of coordination and awareness regarding the resident's participation in activities.
The facility failed to comprehensively assess and follow care plans for pressure injuries in two residents. One resident developed a new heel pressure injury that was not properly documented or off-loaded, while another resident's air mattress was incorrectly set, causing discomfort and improper positioning. Staff interviews confirmed non-compliance with care plans, placing residents at risk for worsening conditions.
The facility did not conduct an annual performance review for a CNA hired in 2023, as confirmed by HR staff. This oversight was identified during a personnel record review and poses a risk to resident care due to potential staff incompetence.
A facility failed to provide necessary behavioral health care and develop a comprehensive care plan for a resident with schizoaffective disorder and Bipolar II. Despite the resident's history of behaviors and symptoms of depression, anxiety, and intrusive thoughts of suicide, the facility did not monitor these symptoms or create a care plan. The resident exhibited episodes of yelling and screaming and reported sensations of bugs crawling on them. Staff confirmed the absence of behavior monitoring and care plan interventions.
The facility did not maintain a clean and homelike environment, as air intake floor vents in resident hallways were found with dust, fuzz, and debris. A resident noted that staff swept dust into the vents, and the Housekeeping Manager admitted the vents were cleaned quarterly, with the last cleaning several months ago. The Administrator in Training acknowledged the issue and expected weekly cleaning.
The facility failed to ensure accurate daily postings of nurse staffing data, with 13 out of 38 days showing inaccuracies or incomplete information. The policy required daily postings at the start of each shift, but from mid-February to late March, several days had errors. The Staffing Coordinator confirmed these discrepancies.
A resident with a history of stroke and falls was improperly restrained by a staff member who tied the resident's gait belt to their wheelchair to prevent falls while attending to other residents. The incident was confirmed by another staff member, who found no negative skin findings. The staff member responsible admitted to the action, citing the resident's high fall risk.
A resident with spinal fractures and chronic pain syndrome did not receive prescribed morphine for pain management due to unavailability on the day of admission. Despite reporting severe pain, nursing staff did not utilize the Cubix system to obtain the medication. The resident received the first dose the following morning, expressing upset over the delay.
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to provide timely access to medical records for a resident who was cognitively intact and had diagnoses including morbid obesity and chronic pain. The resident's attorney requested medical records covering a specific period, but only partial records were provided initially, with progress notes sent and billing documentation omitted. Despite eight follow-up requests from the attorney's office over several months, the complete set of records was not released until approximately four months after the initial request. The Business Office Manager acknowledged receiving multiple communications from the attorney's office but did not follow up due to being too busy. The Administrator confirmed that only a portion of the records was provided at first, and the remaining documents were sent much later. Additionally, the resident personally requested copies of their medical records, including specific documents such as history and physical, progress notes, medication list, care plan, financial data, foot wound care documentation, and transportation notes. There was no documentation indicating that the resident received these records within the required timeframe, and the resident confirmed not having received them about a week after the request. The Administrator acknowledged that the records were not delivered or made available to the resident as required by facility policy.
Dishwasher Temperature Deficiency
Penalty
Summary
The facility failed to ensure that the dishwasher temperatures met the minimum requirements, which placed residents at risk for communicable diseases and un-sanitized dishware and utensils. The facility's Dishwashing in the Dish Machine Policy, dated 1/1/2018, requires testing the dish machine for proper water temperatures and sanitizer levels before washing dishware, and not using the machine if these are not acceptable. On 3/27/25, observations were made of the dishwashing process, where the water temperature was consistently below the required 120 degrees F. Specifically, trays were washed at 90 degrees F, plates at 110 degrees F, forks at 115 degrees F, and plates and cups at 118 degrees F. An external thermometer confirmed the water temperature was 118 degrees F, which was below the required minimum for adequate sanitization. Staff 26, the Dietary Manager, acknowledged that the dishwasher water temperature did not meet the minimum requirements.
Failure to Inform Residents of Arbitration Agreement Rights
Penalty
Summary
The facility failed to ensure that residents were fully informed and understood the binding arbitration agreement, affecting two residents. Resident 16, who was admitted with congestive heart failure, had their legal representative sign the arbitration agreement without being informed of the right to rescind it within the correct timeframe. The legal representative was unaware of the right to rescind the agreement within 30 days, as the facility's agreement inaccurately stated a 10-day rescission period. This discrepancy was confirmed by the Administrator-In-Training. Resident 304, admitted with metabolic encephalopathy and severely impaired cognition, was also affected. The resident's records showed a verbal consent to the arbitration agreement, but the resident did not recall signing or understanding the agreement. The facility's arbitration agreement again inaccurately stated the rescission timeframe, which was confirmed by the Administrator-In-Training. These actions placed residents at risk of being uninformed of their legal rights.
Deficiency in CNA In-Service Training Hours
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistant (CNA) staff received the required 12 hours of in-service training annually, as evidenced by the review of training records for two randomly selected staff members. Staff 9 completed only 7.5 hours, and Staff 18 completed only 1.5 hours of the required training. This deficiency was confirmed through interviews with Staff 2, the Administrator-In-Training, and Staff 3, the Clinical Resource, who acknowledged the shortfall in training hours for these staff members. The facility's policy, last revised on October 15, 2022, mandates that employee education and in-service training are provided to maintain staff competence and knowledge, which was not adhered to in this instance.
Failure to Administer Anticoagulant Leads to Hospitalization
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, which placed the resident at risk for adverse side effects. The resident, who was admitted with vascular dementia and a history of stroke, was prescribed Rivaroxaban, an anticoagulant, to be administered daily. However, the medication was not administered on three consecutive days. This oversight was identified through a facility investigation, which revealed that the medication was available but not given by the responsible LPN. As a result of the missed doses, the resident developed stroke-like symptoms and was sent to the hospital emergency department. The investigation further revealed that the LPN did not notify other staff, contact the provider, or call the pharmacy regarding the missed doses. The LPN admitted to being overwhelmed and failing to follow the appropriate protocol, which included notifying the prescriber and completing a medication error report.
Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was assessed for the safe self-administration of medications, which is a requirement according to the facility's policy. The policy states that a resident may self-administer medications if the interdisciplinary team determines it is safe, based on the resident's capacity to follow directions, comprehend instructions, and securely store medications. However, for Resident 28, who was admitted with a diagnosis of major depressive disorder and had no cognitive impairment according to the Annual MDS, no such assessment was completed. Despite this, medications including mycostatin and trimincolone acetonide were observed on the resident's nightstand, accessible to the resident and others entering the room. Staff interviews revealed that medications should not be left at a resident's bedside without a completed self-administration assessment. Staff 11 (CMA) and Staff 10 (CNA) confirmed that an assessment was necessary and that the nurse should be notified if medications were left at the bedside. Staff 4 (DNS) also confirmed that the resident had not been assessed for safe self-medication and that the medications should not have been left in the room. This oversight placed the resident at risk for unsafe medication administration and potential adverse side effects.
Failure to Assist Resident with Advance Directive
Penalty
Summary
The facility failed to assist a resident in formulating an advance directive, as required by their policy. The policy, dated 10/1/17, mandates that if a resident has not executed an advance directive, the facility should advise the resident and family of their right to establish one and offer assistance if desired. Resident 21, admitted in September 2024 with diagnoses including pneumonia and anxiety, expressed a desire for assistance with an advance directive on a form dated 9/16/24. However, a review of the resident's clinical record showed no advance directive on file. Interviews revealed that although the Social Services Director discussed advance directives with the resident upon arrival, no follow-up assistance was provided. The facility administrator confirmed the lack of follow-up in assisting the resident with formulating an advance directive.
Failure to Provide Adequate Showers for Dependent Resident
Penalty
Summary
The facility failed to ensure that a dependent resident received adequate showers, which compromised personal hygiene and dignity. Resident 16, who was admitted with diagnoses including diabetes and morbid obesity, required partial to moderate assistance with bathing due to moderate cognitive impairment. The resident was incontinent of urine and frequently incontinent of bowel, necessitating regular showers. However, the bathing task logs for February and March 2025 indicated that the resident received showers on only five occasions, with significant gaps between them, including an eight-day period without a shower after admission. Interviews with the resident and staff revealed that the resident was scheduled for showers twice a week but did not receive them consistently. The resident expressed a need for more frequent showers due to incontinence, but missed showers were not rescheduled. Staff members confirmed that showers were often missed due to scheduling constraints, and make-up showers were only possible if time allowed. The Director of Nursing Services confirmed that the resident did not receive the expected minimum of two showers per week, as per facility policy.
Failure to Implement Activity Care Plan for Resident
Penalty
Summary
The facility failed to implement an activity care plan and include a resident in group and individual activities, which placed the resident at risk for isolation and lack of social interaction. The resident, who was admitted with diagnoses including metabolic encephalopathy and cerebral palsy, was non-verbal and dependent on staff for care and mobility. Despite having a care plan that indicated the resident should be invited and encouraged to participate in activities, observations showed that the resident was not invited to group activities such as Bingo and was often found lying in bed without any engagement in preferred activities like music or audio books. Staff interviews revealed a lack of awareness and action regarding the resident's participation in activities. The Activities Director admitted to not inviting the resident to group activities and struggled with engaging non-verbal residents. Additionally, the facility had not procured necessary materials like music or audio books, and there was a lack of coordination between the activities staff and CNAs to assist the resident. The Director of Nursing Services expected staff to follow the care plan, which included assisting with turning on televisions and music, but this was not consistently done, contributing to the deficiency.
Failure to Adhere to Pressure Ulcer Care Plans
Penalty
Summary
The facility failed to ensure comprehensive assessment and adherence to care plans for pressure injuries in two residents. Resident 16, admitted with diagnoses including diabetes and acute kidney failure, developed a new pressure injury on the left heel after admission. The Skin and Wound Evaluation for this injury lacked critical details such as the stage of the injury, wound characteristics, and pain assessment. Despite care plan instructions to off-load pressure from the heel using a boot or pillows, observations revealed the resident's heel was not off-loaded, and staff failed to document any refusals by the resident to comply with these interventions. Resident 15, with a history of spinal stenosis and spondylosis, was at moderate risk for pressure sores and required assistance with bed mobility. The care plan specified the use of a specialty air mattress and off-loading of heels with pillows or boots. However, the air mattress was incorrectly set at 50 pounds instead of the prescribed 120 pounds, leading to discomfort and a sunken position for the resident. Observations showed the resident's heels were not off-loaded, and staff failed to adjust the mattress settings or report the resident's discomfort to nursing staff. Both residents were observed in positions that did not comply with their care plans, and staff interviews confirmed a lack of adherence to prescribed interventions. The facility's failure to follow care plans and ensure proper assessment and documentation of pressure injuries placed residents at risk for worsening conditions.
Failure to Conduct Annual Performance Review for CNA
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received annual performance reviews, specifically for one CNA out of four randomly selected staff members. This deficiency was identified during a review of personnel records conducted with the Human Resources staff. It was found that a CNA, hired on November 6, 2023, did not have a completed annual performance evaluation. This oversight was confirmed by the Human Resources staff, placing residents at risk due to the potential lack of care by competent staff.
Failure to Provide Comprehensive Behavioral Health Care Plan
Penalty
Summary
The facility failed to provide necessary behavioral health care and services and develop a comprehensive, person-centered behavioral health care plan for a resident with schizoaffective disorder and Bipolar II. The resident, admitted in February 2025, had a history of behaviors and was prescribed anti-psychotic medications. Despite being identified as having mild depression, anxiety, and intrusive thoughts of suicide, the facility did not monitor these symptoms or develop a care plan to address the resident's anxiety, feelings of helplessness, withdrawal, lack of coping skills, or thoughts of suicide. The resident exhibited multiple episodes of yelling and screaming, reported sensations of bugs crawling on them, and expressed a need for medication to alleviate these sensations. Staff interviews revealed that the resident was often labile, easily frustrated, and had outbursts, yet there was no behavior monitoring or care plan interventions in place. The Social Service Director and CNAs confirmed the absence of a comprehensive behavioral care plan and monitoring for the resident's behaviors. The Director of Nursing Services acknowledged that residents with mental health diagnoses should be monitored and care planned for behaviors, confirming that the resident's triggers were not identified, and strategies to help them feel better were not devised.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment, as evidenced by the accumulation of dust, fuzz, and paper debris on and below the grates covering the air intake floor vents in the north and south residents' hallways and the entrance hallway. These observations were made over several days. A resident reported that staff swept dust from the floors into the vents, contributing to their unclean state. The Maintenance Manager indicated that cleaning the floor vents was a housekeeping responsibility, while the Housekeeping Manager admitted that the vents were cleaned quarterly, with the last cleaning occurring several months prior. The Administrator in Training acknowledged the dirty vents and stated an expectation for weekly cleaning by housekeeping.
Inaccurate Nurse Staffing Reports
Penalty
Summary
The facility failed to ensure the accuracy of the Direct Care Staff Daily Report (DCSDR) postings for 13 out of 38 days reviewed. This deficiency was identified through interviews and record reviews, which revealed that the nurse staffing data was either inaccurate or incomplete on specific days. The facility's policy required daily postings of nurse staffing data at the beginning of each shift, including the facility name, current date, total number of actual hours worked by licensed and unlicensed staff, and the resident census. However, from February 15, 2025, to March 24, 2025, the DCSDRs were found to have inaccuracies or missing information on several days. On March 27, 2025, the Staffing Coordinator confirmed the inaccuracies and incomplete information on the identified days.
Improper Use of Physical Restraints on a Resident
Penalty
Summary
The facility failed to ensure that residents were free from physical restraints, as evidenced by the case of a resident who was improperly restrained. The resident, admitted in May 2023 with a history of stroke and repeated falls, was identified as a high fall risk. The care plan for the resident included encouraging transfers to prevent further falls. However, on June 7, 2023, it was reported that the resident had been placed in a device that limited their ability to stand. A staff member, identified as Staff 11, tied the resident's gait belt to their wheelchair to prevent falls while attending to other residents. The incident was confirmed by Staff 3, who observed the restraint and conducted a skin check with no negative findings. Staff 11 admitted to tying the gait belt to the wheelchair, citing the resident's high fall risk and the need to manage care for other residents. The facility's investigation included a handwritten statement from Staff 11, acknowledging the action taken to keep the resident from falling. The facility's administrator and director of nursing services were informed of the findings but provided no additional information.
Removal Plan
- Educated the staff responsible and placed on corrective discipline;
- Provided in-service training to all nursing staff for abuse and neglect which included the use of restraints;
- Provided signature sheet verifying nursing staff had completed the training.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who was admitted with spinal fractures and chronic pain syndrome. Upon admission, the resident was prescribed morphine tablets to be administered every 12 hours for pain management. However, the resident's medication administration record (MAR) indicated that the morphine was not administered during the evening shift on the day of admission due to the medication being unavailable. The initial pain assessment conducted by a registered nurse revealed that the resident reported a severe pain level of 10. Despite the facility's procedures requiring immediate response to pain complaints and the availability of a medication dispensing system (Cubix) for emergent care needs, there were no documented efforts by the nursing staff to obtain the pain medication from the Cubix. The morphine was eventually delivered to the facility in the early hours of the following day, and the resident received the first dose later that morning. The resident expressed upset over the delay in receiving the medication. Interviews with staff confirmed the lack of timely administration and absence of progress notes explaining the delay.
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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) |
|---|---|---|---|---|
| Gracelen Care Center | 0.4 mi | ★★★★★ | 5 | 0 |
| Cascade Terrace Post Acute | 1.1 mi | ★★★★★ | 5 | 0 |
| Avalon Care Center - Portland | 1.5 mi | ★★★★★ | 4 | 0 |
| Marquis Mill Park | 1.5 mi | ★★★★★ | 13 | 0 |
| Cedar Crossings | 2.1 mi | ★★★★★ | 14 | 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.