Below average — CMS composite of the measures below.
The next survey window likely opens around April 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 Tigard Rehabilitation And Care during CMS and state inspections, most recent first.
A nurse failed to disinfect a shared glucometer between resident CBG checks, using the same unsanitized meter for two residents instead of cleaning it after each use. The nurse also performed wound care for a resident on EBP while wearing gloves and a mask but no gown, despite an EBP sign on the door and facility expectations for gown and glove use during high-contact care.
A resident with dysphagia and aspiration precautions was given a meat sandwich without staff checking the current diet order, and the resident choked until a nearby employee performed the Heimlich maneuver. Another resident with stroke-related swallowing issues and a no-straw precaution was observed with a straw in a juice cup despite staff recognizing the resident was an aspiration risk. The incidents involved failure to follow ordered diet texture and aspiration precautions, including supervision and no-straw restrictions.
A RN failed to disinfect a shared glucometer between resident uses, did not follow a resident’s insulin order by giving Novolog when CBG was below the ordered threshold, and missed multiple PRN Hydralazine doses for another resident despite BP readings meeting the physician’s parameters. During wound care, the RN entered a resident’s room with an EBP sign posted but did not wear a gown, and the DNS confirmed staff were expected to follow EBP and medication orders as written.
Medication storage and labeling failures were observed when an open vial of tuberculin was found in the med room refrigerator without an open date, refrigerator temperature logs were incomplete and showed a temperature below the required range, and a med cart was left unlocked and unattended with keys hanging out. An open treatment cart also contained two vials of Admelog insulin without open dates, and the DNS and an LPN acknowledged the issues.
Failure to Ensure Kitchen Staff Wore Hair Restraints: A Cook was observed prepping food with her hair not fully covered and without a required hair restraint, despite the facility policy requiring food and nutrition service staff to wear hair restraints. The Cook acknowledged the issue, and the Dietary Mgr confirmed staff were to wear hair restraints.
The facility failed to complete monthly psychoactive drug reviews for a resident with bipolar disorder who was receiving Abilify and bupropion. A psychoactive drug review noted no changes and planned reassessment the following month, but no further review was documented, and the SSD and DNS acknowledged the resident had not been reassessed since October 2025.
A resident with urinary incontinence and intact cognition had a care plan that included keeping a bedside urinal within reach, but observations found no urinal at the bedside. The resident, a CNA, an LPN, and the DNS all stated the resident did not use a urinal and that the intervention was not individualized, with the DNS noting it may have been selected in error from the care plan template.
A resident with hypertensive heart disease, CKD, and HF had two conflicting physician orders for BP monitoring and PRN Hydralazine. The record showed multiple BP readings outside the ordered parameters, but the MARs did not show PRN Hydralazine being given. An RN said he likely rechecked the BP but did not document it, an LPN was unaware of the order discrepancy, and the DNS acknowledged the orders contained errors and the PRN medication was not administered as ordered.
Failure to maintain ROM and mobility: A resident with muscle wasting atrophy and documented unilateral ROM impairment had a therapy recommendation for daily restorative ROM to maintain function, but the care plan did not reflect that recommendation. The resident reported stiffness, reduced ability to do normal daily activities, and not receiving therapy, while a CNA and OT noted a decline in ROM and difficulty with routine tasks; the DNS confirmed the care plan omission led to the decline.
A resident received Novolog insulin contrary to the physician order, which required 2 units before meals only when CBG was greater than 150. Review of the DAR showed the resident was given insulin 55 times when blood sugars were below 150, and both an RN and an LPN acknowledged administering insulin without following the order as written; the DNS also acknowledged the resident was not medicated per physician orders.
Unsecured medication cart screens exposed resident information when two unattended carts were observed with open computer screens displaying a resident’s name, DOB, and medication administration data. An LPN and the DNS acknowledged the screens were left open, and the DNS stated the screen was expected to be locked when unattended.
Failure to obtain vaccine consent and offer recommended immunizations: Two residents had issues with pneumococcal and influenza vaccination documentation. One resident with Parkinsonism was eligible for a CDC-recommended pneumococcal vaccine but was not offered it, and another resident with a stroke diagnosis received pneumococcal and flu vaccines without consents found in the EMR or paper chart; the resident did not recall receiving education on the risks and benefits, and the DNS could not locate the consent forms.
The facility failed to offer the COVID-19 vaccine to two residents reviewed for immunizations. One resident had Parkinsonism and another had osteomyelitis of the vertebrae; both were documented as eligible, but the Corporate IP stated the vaccine was not offered.
A resident admitted with heart failure and diabetes was found to have a blister on the left knee during the admission assessment. Although the care plan noted impaired skin integrity, staff did not implement monitoring or complete further assessments of the wound, and the required documentation and alert charting were not initiated.
A resident with osteomyelitis developed new pressure ulcers that were not comprehensively assessed or treated in a timely manner. After a CNA reported an open sore, an LPN cleaned and covered the wound but did not measure it, obtain provider orders, or document treatment. Wound care orders and comprehensive assessment were delayed by two days, and wound care was not provided until the following day, contrary to facility protocol and national guidelines.
The facility did not maintain accurate records or account for all controlled drugs, resulting in missing narcotic medication for two residents. Staff interviews confirmed knowledge of the missing medication, but the facility was unable to determine its whereabouts, indicating a failure to follow required procedures for reconciling and documenting controlled substances.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility failed to monitor refrigerator temperatures and label food items properly, risking foodborne illnesses. Observations showed that temperatures were recorded only once, and food items lacked dates or names. Staff interviews revealed a lack of awareness and adherence to the facility's policy, leading to the deficiency.
A resident with limited English proficiency was not provided with important documents in their preferred language, Spanish, despite needing an interpreter. This included critical documents like POLST and Medicare notices. Staff confirmed the resident's language needs, but the facility failed to ensure communication was in a language the resident could understand.
The facility did not deliver resident mail on Saturdays, contrary to its policy requiring mail delivery within 24 hours, including weekends. Residents reported this issue during a council meeting, and the Activities Director confirmed that mail was only distributed Monday through Friday. The Administrator acknowledged that mail should be delivered on the same day it arrives.
A facility failed to create a comprehensive care plan for a resident with diabetes and chronic suicidal ideation. Despite assessments and progress notes indicating mood issues, depression, and behavioral problems, these concerns were not included in the care plan. Staff interviews revealed a lack of awareness and monitoring of the resident's mood, with some staff acknowledging the resident's expressions of wanting to die. The DNS expected these issues to be addressed, but the Social Services Director did not perceive them as significant enough for the care plan.
A resident with a diabetic foot ulcer and venous ulcers did not receive timely wound care upon admission. Despite being aware of the wounds, the facility failed to obtain treatment orders for over a month, leading to a delay in care. This oversight was confirmed by staff, highlighting a significant lapse in the facility's wound management protocol.
A resident with malnutrition and type 1 diabetes experienced significant weight loss, dropping from an average of 205.5 pounds to 174.6 pounds. Despite this, the facility delayed a reweigh and did not implement new nutritional interventions or review the resident in the Nutritional at Risk group in a timely manner. The RD acknowledged these delays, which placed the resident at risk for continued weight loss.
The facility did not conduct annual performance reviews for four CNAs, as confirmed by the DNS and Staffing Coordinator. This oversight placed residents at risk of receiving care from potentially incompetent staff.
A facility failed to ensure resident dignity and respect when a verbal altercation between two residents resulted in one resident spitting in the other's face. The incident, witnessed by staff, occurred over a borrowed wheelchair. Despite one resident's denial, staff confirmed the spitting incident, and both residents were placed on safety monitoring.
A resident with a history of inappropriate sexual behavior was found with their hand inside another resident's brief while the latter was asleep. Both residents had severe cognitive impairments, and the incident was witnessed by a staff member. The facility's records indicated prior knowledge of the offending resident's behavior, yet the incident occurred, placing residents at risk for repeat abuse.
A facility failed to provide wound care for a diabetic resident as per physician orders. The resident's orders required specific wound care procedures, including cleaning, applying AD ointment, and securing with bordered foam, to be performed three times weekly. However, no wound care was documented for over two weeks, as confirmed by the DNS.
Glucometer Not Disinfected Between Residents; PPE Not Used for EBP Wound Care
Penalty
Summary
The facility failed to ensure a community-use glucometer was disinfected between resident blood glucose checks. On 5/6/26, Staff 3 used a True Metrix Blood Glucose System to obtain a CBG for Resident 53 and then placed the meter on the cart without disinfecting it. During continued observation, Staff 3 later gathered the same soiled glucometer and prepared to enter Resident 9's room without cleaning it first, and only disinfected it after the State Surveyor intervened. Staff 3 stated he cleaned glucometers only several times per shift or when visibly soiled, rather than after each resident use. The report states the True Metrix manufacturer instructions required disinfection of the meter with EPA-registered wipes between each resident, and the facility's policy also required disinfection after each individual patient use. Staff 2, the DNS, confirmed staff were to use disinfecting wipes on the glucometer between each resident. Staff 2 also provided a list of residents requiring CBG checks, including Resident 9, who had Hepatitis C, and Resident 60, who had MRSA. Staff 3 worked on all three halls of the facility. The facility also failed to use proper PPE for a resident on Enhanced Barrier Precautions. Resident 10, admitted with diagnoses including right femur fracture and a history of ESBL infection, had an EBP sign on the room door. On 5/7/26, Staff 3 entered the room to perform wound care while wearing gloves and a face mask but no gown, completed the wound care to the resident's left knee, removed gloves, and exited the room. Staff 3 stated he did not think a gown was necessary and was unsure whether the precaution sign was current. Staff 14, the Corporate IP, stated she expected staff to follow EBP when performing wound care.
Choking and Aspiration Precautions Not Followed
Penalty
Summary
The facility failed to ensure foods and fluids were served in a manner to prevent accidental choking for two residents with swallowing-related precautions. One resident had diagnoses including stroke and dysphagia, a BIMS score of 8 indicating moderate cognitive impairment, and an MDS noting coughing or choking during meals. The resident’s care plan called for 1:1 assistance at meals, upright positioning, small bites, slow rate, and a soft and bite-sized diet with thin liquids. The resident choked after being given a meat sandwich by a CNA who was not the assigned caregiver and who did not check the resident’s current diet texture. The CNA stated she believed the resident had been on a regular diet previously and assumed the diet had not changed. During the incident, the resident took several bites, began choking, coughed up food, requested water, continued to cough, and then became silent. A maintenance director nearby observed the resident appearing purple and choking and performed the Heimlich maneuver, which expelled a large piece of meat. A second resident had diagnoses including stroke and dysphagia, with speech evaluation findings of dysphagia when using a straw with thin liquids. The resident’s MDS identified choking risk and need for a mechanically altered diet, and the care plan required upright positioning during meals, distant supervision, and no straws. Despite this, the resident was observed with a straw in a half-empty cup of grape juice, and staff acknowledged the resident was an aspiration risk and that it was not safe to use a straw.
Failure to Follow Infection Control and Medication Orders
Penalty
Summary
The facility failed to ensure staff adhered to professional standards related to disinfection of a common-use glucometer, following physician orders, unnecessary medications, and infection control during wound care. A registered nurse obtained a capillary blood glucose reading for one resident and then left the glucometer on the cart without disinfecting it. After completing other tasks for about 20 minutes, the nurse picked up the same unsanitized glucometer to enter another resident’s room. When questioned, the nurse stated glucometers were cleaned several times per shift or if visibly soiled, but not between every resident use, and then disinfected the meter only after being prompted. The Director of Nursing stated the expectation was for staff to use disinfecting wipes between resident use. The facility also failed to follow physician orders for insulin and PRN antihypertensive medication. One resident with diabetes had a physician order for Novolog insulin 2 units before meals only if CBG was greater than 150, but review of the diabetic administration record showed insulin was given on multiple occasions when blood sugars were below 150. The nurse stated he did not fully read the order and used his clinical judgment instead of the written parameters. Another resident with hypertensive heart and chronic kidney disease had an order for Hydralazine 25 mg every 8 hours as needed for SBP greater than 160 or DBP greater than 80, but the record showed eleven instances from 4/5/26 through 5/3/26 when blood pressure met the ordered parameters and the medication was not given. The nurse could not explain why the medication was not administered, and the DNS acknowledged the medication should have been given according to the order.
Medication Storage and Labeling Failures
Penalty
Summary
The facility failed to ensure that medications and biologicals were stored and labeled according to accepted professional principles. On 5/6/26, an open vial of tuberculin was observed in the medication room refrigerator without an open date, and Staff 3 (RN) acknowledged that it was open and unlabeled. Staff 2 (DNS) stated that open medications were expected to have open dates. The refrigerator also contained insulin and vaccines, and the temperature log was incomplete on multiple dates in April and May 2026. In addition, the temperature log showed the refrigerator was 34 F on 4/19/26, below the posted required range of 36 F to 46 F, and Staff 2 acknowledged both the incomplete logs and the out-of-range temperature. The facility also failed to keep medication storage secured. During continuous observation on 5/6/26, the medication cart on the 100 hall was left unlocked and unattended, with the keys hanging out of the cart while medications were inside. Staff 2 (DNS) acknowledged the cart was unlocked and unattended. On 5/8/26, the 200 hall treatment cart was observed to contain two open vials of Admelog insulin without open dates, and Staff 13 (LPN) acknowledged the vials were open without dates. Staff 2 stated that open insulin was expected to be labeled with open dates.
Failure to Ensure Kitchen Staff Wore Hair Restraints
Penalty
Summary
The facility failed to ensure that kitchen staff wore hair restraints for 1 of 1 staff member reviewed for the kitchen. The facility's 2001 Food Preparation and Service Policy stated that food and nutrition service staff were to wear hair restraints, such as a hair net, hat, or beard restraint, so that hair did not contact food. On 5/4/26 at 10:10 AM, Staff 6, a Cook, was observed in the kitchen at the counter prepping food while wearing a bandana around her head and having her hair in a clip; her hair was not fully covered and she was not wearing a hair restraint. At 10:11 AM, Staff 6 acknowledged she was not wearing a hair restraint, and Staff 7, the Dietary Manager, stated staff were to wear hair restraints and acknowledged that Staff 6 was not wearing one.
Failure to Complete Monthly Psychoactive Drug Review
Penalty
Summary
The facility failed to assess the appropriateness and effectiveness of psychotropic medication use for one sampled resident with bipolar disorder. Resident 5 was admitted in 2022 with diagnoses including bipolar disorder and had physician orders for Abilify, an antipsychotic, and bupropion, an antidepressant, for that condition. A psychoactive drug review dated 10/16/25 noted the resident had been readmitted with bipolar disorder, was receiving Abilify and bupropion, and that no changes were recommended, with depressive symptoms to be monitored and reassessed the following month. The medical record showed no psychoactive drug review was completed after that date, and Staff 8 and Staff 2 acknowledged that the resident had not been reassessed with a psychoactive drug review since October 2025.
Non-Individualized Care Plan Intervention for Urinary Incontinence
Penalty
Summary
The facility failed to ensure care plan interventions were individualized for one resident reviewed for ADLs. The resident was admitted in 1/2023 with diagnoses including urinary incontinence, and the 1/22/26 Annual MDS showed a BIMS score of 15, indicating the resident was cognitively intact, with bladder and bowel incontinence always present. The 2/6/26 care plan identified episodes of bladder incontinence related to limited mobility and cognitive impairment and included the intervention to ensure a bedside urinal was within reach, encourage usage, and check and empty it at regular intervals. However, observations from 5/4/26 through 5/6/26 between 11:50 AM and 4:30 PM found no urinal cup at the resident’s bedside. The resident stated on 5/6/26 that there had never been a urinal at bedside and that the resident was physically unable to use one prior to admission. A CNA stated the resident did not have a bedside urinal and had never used one, an LPN stated use of a urinal was impossible due to the resident’s limitations, and the DNS stated the urinal intervention was listed as an option in the care plan template and may have been selected in error, and that staff had not previously identified the discrepancy.
Failure to Clarify and Follow BP Medication Orders
Penalty
Summary
The facility failed to clarify and follow physician orders for a resident admitted with hypertensive heart and chronic kidney disease with heart failure and chronic kidney disease stages 1 through 4. The resident’s annual MDS showed a BIMS score of 15, indicating cognitive intactness. The record contained two different physician orders related to blood pressure management: one order from 7/21/24 directed blood pressure checks three times a day with PRN Hydralazine for DBP greater than 90 and SBP greater than 140, while another order from 2/1/24 directed Hydralazine 25 mg by mouth every 8 hours as needed for SBP greater than 160 or DBP greater than 80. The record showed no indication that the discrepancy between these orders was identified or clarified. Blood pressure readings from 4/1/26 through 5/7/26 showed multiple values outside the ordered parameters, including repeated elevated systolic and diastolic readings at 0700, 1500, and 2300 hours. Review of the April and May MARs showed no indication that PRN Hydralazine was administered on the identified dates. During interviews, an RN stated he did not check the resident’s blood pressure as documented, then said he probably rechecked it 30 minutes later and it was fine, but acknowledged the rechecks were not documented and that he did not identify the discrepancy in the physician orders. An LPN stated she routinely obtained the resident’s blood pressure, did not recall administering PRN Hydralazine, and was unaware of the discrepancy in orders. The DNS acknowledged there were errors and discrepancies in the physician orders and that PRN Hydralazine was not administered according to the orders.
Failure to Maintain ROM and Mobility
Penalty
Summary
The facility failed to provide appropriate treatment and services to maintain and prevent a potential decrease in a resident’s range of motion and mobility. Resident 49 was admitted with diagnoses including muscle wasting atrophy, and therapy documentation showed the resident was to participate in a restorative ROM program to maintain the highest level of function for the upper extremities. Subsequent MDS assessments documented ROM impairment to both upper and lower extremities on one side, with a change from minimal assistance with upper body dressing to substantial/maximal assistance. The care plan identified the resident as at risk for pain related to decreased mobility and listed exercise as an intervention, but no additional information was found related to preserving the resident’s mobility. The resident stated not receiving therapy and reported a decline in ability to perform normal daily activities due to stiffness and not moving enough. A CNA stated the resident had experienced a decline in ROM over the past few months and was struggling with tasks such as oral care because of inability to reach items on the overbed table. The OT stated the resident had last been assessed in 11/2025 and recommended daily ROM exercises to maintain current mobility and prevent decline, and the DNS confirmed the care plan did not reflect those recommendations and that this led to a decline in the resident’s ROM ability.
Insulin Administered Contrary to Physician Order
Penalty
Summary
The facility failed to administer insulin as ordered for one of five sampled residents, Resident 5, who had a physician order dated 2/20/26 for Novolog insulin 2 units before meals only if the capillary blood sugar (CBG) was greater than 150. Review of the April and May 2026 Diabetic Administration Record showed that from 4/1/26 through 5/6/26, Resident 5 received 2 units of insulin 55 times when blood sugars were below 150. Staff 3, an RN, administered insulin to Resident 5 on 4/17/26, 4/24/26, 5/1/26, and 5/6/26 when the blood sugar was under 150 and stated he was not aware the order required a blood sugar level over 150, explaining he did not fully read the order and used his clinical judgment because the resident's blood sugar tended to run high after meals. Staff 4, an LPN, administered insulin on multiple dates when the blood sugar was under 150 and stated he was not aware the order required insulin only when the blood sugar was over 150 due to the way the order was written. The DNS acknowledged that Resident 5 was not administered insulin per physician orders.
Unsecured Medication Cart Screens Exposed Resident Information
Penalty
Summary
The facility failed to ensure resident medical records were kept secured and confidential for 2 of 2 random observations. On 5/6/26, continuous observation of the 100 hall medication cart from 11:14 AM to 11:42 AM showed the cart left unattended with the computer screen open and displaying Resident 41's name, date of birth, and medication administration information. At 11:42 AM, Staff 2, the DNS, acknowledged the cart was unattended and the screen was open with resident information displayed, and stated the screen was supposed to be locked when the cart was unattended. On 5/8/26, continuous observation of the 200 hall medication cart from 9:04 AM to 9:06 AM showed the cart left unattended with the computer screen open and displaying Resident 30's name, date of birth, and medication administration information. At 9:06 AM, Staff 12, an LPN, acknowledged the cart was unattended and the screen was open with resident information displayed, and at 9:40 AM Staff 2 stated the expectation was for staff to lock the computer screen when it was unattended.
Failure to Obtain Vaccine Consent and Offer Recommended Immunizations
Penalty
Summary
The facility failed to offer and obtain consent before administering influenza and pneumococcal vaccinations for 2 of 5 sampled residents reviewed for immunizations. The deficiency was identified during interview and record review and involved residents who were not documented as having received the required education and consent process before vaccination, as described in the facility’s revised 3/2022 pneumococcal and influenza vaccination policies. Resident 11, admitted in 2022 with a diagnosis of Parkinsonism, had received Prevnar 13 in 7/2023 and was eligible for the CDC-recommended pneumococcal vaccine, but the vaccine was not offered to the resident. Resident 28, admitted in 2024 with a diagnosis of stroke, received the latest pneumococcal vaccine in 3/2025 and an influenza vaccine in 2/2026, but the EMR and paper record did not contain pneumococcal or influenza consents. Resident 28 did not recall receiving education about the risks and benefits of either vaccine, and the DNS stated the consents could not be located and that the previous DNS had been responsible for immunizations and kept the files in her office.
Failure to Offer COVID-19 Vaccine to Eligible Residents
Penalty
Summary
The facility failed to ensure residents were offered the COVID-19 vaccine for 2 of 5 sampled residents reviewed for immunizations. Resident 11, admitted in 2022 with a diagnosis of Parkinsonism, had an immunization record showing the COVID-19 vaccine was not offered. Resident 62, admitted in 2024 with a diagnosis of osteomyelitis of the vertebrae, also had an immunization record showing the COVID-19 vaccine was not offered. On interview, the Corporate IP stated both residents were eligible for the COVID-19 vaccine, but it was not offered to them.
Failure to Monitor Non-Pressure Skin Wound
Penalty
Summary
The facility failed to monitor a non-pressure skin wound for one resident who was admitted with diagnoses including heart failure and diabetes. Upon admission, a clinical progress note documented redness and a small healing blister on the resident's front left knee. The care plan identified impaired skin integrity due to the blister and immobility. However, a review of the medical record and treatment administration record (TAR) showed no assessment or monitoring of the wound during the resident's stay. Staff confirmed that although the blister was identified during the admission assessment, monitoring was not implemented, and no further assessments were completed. Facility leadership stated that the expected protocol for skin impairments was not followed, as the blister was not documented for ongoing monitoring or alert charting.
Failure to Timely Assess and Treat Newly Identified Pressure Ulcers
Penalty
Summary
The facility failed to ensure that newly identified pressure ulcer wounds were comprehensively assessed and that wound care orders were obtained and implemented for a resident with a diagnosis of osteomyelitis of the vertebrae. After admission, a CNA notified an LPN of an open sore on the upper part of the resident's buttock. The LPN observed, cleaned, and covered the wound, and initiated a Skin Integrity Report, but did not measure the wound, obtain provider orders, document wound treatment, or initiate any wound care protocol on the Treatment Administration Record (TAR) at that time. There was no evidence in the health record of a comprehensive wound assessment, including measurement, location, stage, or other characteristics, between the initial identification of the wound and two days later. Wound care orders were not obtained until two days after the wound was first identified, and wound care was not provided until the following day. The Director of Nursing Services confirmed that the wound was not comprehensively assessed and measured until two days after it was first identified, and that there was no evidence of wound care being provided during that period. This lapse in timely assessment and intervention did not follow the facility's protocol or national guidelines for pressure ulcer care.
Failure to Maintain Accurate Narcotic Drug Records
Penalty
Summary
The facility failed to ensure that narcotic drug records were properly maintained and that an accurate account of all controlled drugs was kept for one of three narcotic books reviewed. According to the facility's policy, nursing staff are required to count controlled medication inventory at the end of each shift, with both the incoming and outgoing nurses reconciling and documenting the count, and reporting any discrepancies to the Director of Nursing Services (DNS). However, a review of records revealed that narcotic medication for two residents was missing and unaccounted for, and the facility was unable to determine what happened to the missing medication. Staff interviews confirmed awareness of the missing narcotic medication but did not provide information on its whereabouts. The deficiency was identified when a former DNS discovered two missing narcotic cards during a review of the facility's narcotic books. Subsequent investigation and staff interviews indicated that the required procedures for reconciling and documenting controlled substances were not followed, resulting in the loss of narcotic medication. The lack of proper record-keeping and reconciliation placed residents at risk for drug diversion.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Monitor and Label Food Storage
Penalty
Summary
The facility failed to ensure proper monitoring and labeling of food storage in two refrigerators, which placed residents at risk for potential foodborne illnesses. Observations revealed that the refrigerator used to store resident food items in the dining room had a temperature log, but temperatures were only recorded once on 1/10/25. Additionally, food items in the refrigerator were found without dates or names. Staff interviews indicated a lack of awareness and adherence to the facility's policy, which required daily temperature checks and proper labeling of food. The Dietary Manager was unaware of the monitoring process for the resident foods refrigerator, and a CNA was unsure of the labeling policy. This lack of compliance with the facility's policy led to the deficiency.
Failure to Provide Language-Appropriate Communication
Penalty
Summary
The facility failed to ensure that a resident, who primarily spoke Spanish and required an interpreter, received communication in a language they could understand. The resident was admitted with a diagnosis of diabetes and had a care plan indicating a preference for Spanish. Despite this, several important documents, including Portable Orders for Life-Sustaining Treatment (POLST), Notices of Medicare Non-Coverage, and SNF Discharge Instructions, were provided to the resident in English only. Interviews with staff confirmed the resident's limited English proficiency and the need for translation services, yet the facility did not provide documents in Spanish, leading to a lack of involvement in the resident's care.
Failure to Deliver Resident Mail on Saturdays
Penalty
Summary
The facility failed to ensure that resident mail was delivered on Saturdays, as required by their Mail and Electronic Communication policy revised in 2017. This policy mandates that mail and packages be delivered to residents within twenty-four hours of delivery to the premises, including Saturdays. During a resident council meeting, residents reported that their mail was not delivered on Saturdays. Staff 20, the Activities Director, confirmed that mail was only delivered to residents from Monday through Friday, and any mail received on Saturdays was not distributed until the following Monday. Staff 1, the Administrator, acknowledged that resident mail should be delivered on the same day it arrives at the facility.
Failure to Develop Comprehensive Care Plan for Resident with Mood Issues
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident admitted with diagnoses including diabetes and chronic suicidal ideation. Despite multiple assessments and progress notes indicating the resident's mood issues, including depression, suicidal ideation, and behavioral problems such as yelling and combativeness, the facility did not include these concerns in the resident's care plan. Interviews with staff revealed a lack of awareness and monitoring of the resident's mood and behaviors, with some staff members acknowledging the resident's expressions of wanting to die and feelings of helplessness. The Director of Nursing Services expected mood and behavior issues to be addressed in the care plan, yet the Social Services Director did not perceive the resident's mood issues as significant enough to warrant inclusion in the care plan. This oversight placed the resident at risk for unmet needs, as there was no structured plan to monitor or address the resident's mental health and behavioral issues, despite the resident's history and ongoing expressions of distress.
Failure to Provide Timely Wound Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with multiple wounds, including a diabetic foot ulcer and venous ulcers, upon admission. The resident was admitted with a known right foot ulcer, but daily skilled evaluations from early October to early November did not include assessments of this ulcer. Additionally, physician progress notes during this period did not address the ulcer. A skin check assessment in late November revealed additional venous ulcers on the resident's left leg, which were reportedly present since admission, yet no treatment orders were in place. It was not until late November that the facility requested and obtained orders for wound care for the resident's right foot ulcer and newly identified wounds on the left lower extremity and buttocks. Staff confirmed that the facility was aware of the wounds upon admission but failed to secure treatment orders until over a month later. This oversight placed the resident at risk for worsening wounds due to the lack of timely and appropriate care.
Failure to Timely Address Resident's Weight Loss
Penalty
Summary
The facility failed to ensure that a resident was properly assessed after significant weight loss was identified. Resident 34, who was admitted with diagnoses including malnutrition and type 1 diabetes, experienced a notable weight loss from an average of 205.5 pounds to 174.6 pounds over a period of time. Despite the identification of this weight loss on 9/23/24, a reweigh was not conducted until 10/7/24, two weeks after the initial request. During this period, no new nutritional interventions were implemented, and the resident was not reviewed by the Nutritional at Risk (NAR) group until 10/22/24, which was three days after readmission from a hospital stay related to diabetes. Staff 13, the Registered Dietitian (RD), acknowledged that the reweigh recommendation was not completed in a timely manner and that the resident was not reviewed in the NAR group within the expected timeframe. This delay in assessment and intervention placed the resident at risk for continued weight loss. Observations made in January 2025 indicated that the resident was capable of feeding themselves and consumed 100% of their meals, suggesting that earlier intervention might have been beneficial.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received annual performance reviews, as evidenced by the lack of performance reviews for four randomly selected CNA staff members. On January 14, 2025, the Director of Nursing Services (DNS) was unable to provide the requested performance reviews for the identified CNAs. The following day, the Staffing Coordinator acknowledged that no performance reviews had been completed for these staff members. This deficiency placed residents at risk for receiving care from potentially incompetent staff.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by an incident involving two residents. Resident 2, who was admitted to the facility with hyperlipidemia, was involved in a verbal altercation with Resident 1, who had chronic systolic heart failure. The altercation occurred in the facility parking lot when Resident 2 requested the return of a spare wheelchair borrowed by Resident 1. During the altercation, Resident 1 was observed spitting in the face of Resident 2, which was confirmed by multiple staff witnesses. Staff 3 and Staff 4, who witnessed the incident, intervened to separate the residents and ensure their safety. Resident 2 expressed feeling offended and disrespected by the incident but declined a physical assessment, stating no injuries were sustained. Despite Resident 1's denial of spitting, both staff members confirmed the act occurred. The incident was documented in a Facility Reported Incident, and both residents were placed on safety monitoring to prevent further occurrences.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect residents from sexual abuse, as evidenced by an incident involving two residents with severe cognitive impairments. Resident 1, who has a history of trauma related to domestic violence, was found to have been sexually abused by Resident 2, who has a history of inappropriate sexual behavior. On the evening of April 29, 2024, Resident 2 was discovered with their hand inside Resident 1's brief while Resident 1 was asleep. This incident was witnessed by a staff member, who observed Resident 2 exposing Resident 1's right hip and buttocks. The facility's records indicated that Resident 2 had been previously identified with inappropriate sexual behavior, yet was able to access Resident 1's room and engage in the abusive act. The incident was reported to the police, and it was acknowledged by the facility's administrator and director of nursing services. The failure to prevent this incident placed residents at risk for potential repeat sexual abuse incidents.
Failure to Provide Diabetic Wound Care
Penalty
Summary
The facility failed to provide appropriate wound care treatment according to physician orders for a resident with a diabetic wound. The resident, admitted in May 2023 with a diagnosis of diabetes, had specific physician orders dated October 10, 2023, for the care of a diabetic wound on the right toe. The orders required the wound to be cleaned with wound cleanser, a thin layer of AD ointment to be applied to the wound and periwound, and the wound to be secured with bordered foam. The dressing was to be changed three times per week and as needed. However, a review of the resident's October 2023 Treatment Administration Record (TAR) revealed that no wound care was documented as being performed from October 11, 2023, through October 27, 2023. This lapse in care was confirmed by Staff 2, the Director of Nursing Services (DNS), on April 10, 2024, indicating a failure to adhere to the prescribed wound care regimen.
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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 Tigard
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avamere Rehabilitation Of King City | 1.3 mi | ★★★★★ | 13 | 0 |
| Marquis Tualatin Post Acute Rehab | 3.1 mi | ★★★★★ | 9 | 1 |
| Pearl At Kruse Way, The | 3.4 mi | ★★★★★ | 3 | 0 |
| Beaverton Post Acute Care Of Cascadia | 4 mi | ★★★★★ | 1 | 0 |
| West Hills Health & Rehabilitation | 4.2 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.