Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Portland during CMS and state inspections, most recent first.
A CNA failed to change gloves or perform hand hygiene while providing incontinent care to a resident with COPD, CHF, vascular dementia, and severe cognitive impairment. The CNA touched the resident’s curtain, blanket, and pillows with gloved hands, then cleaned the perineal area and continued to the gluteal area without glove changes or hand hygiene. The ADON and DON stated the CNA should have removed gloves and cleaned hands after contact with the resident’s environment and before moving from the soiled body site to the clean body site.
A resident with essential hypertension had an order for Metoprolol 12.5 mg PO four times daily with parameters to hold the dose if SBP was below 110 or DBP below 60, yet nursing staff repeatedly administered the medication without documenting blood pressure readings at the time of dosing. The MAR listed scheduled administration times but lacked corresponding BP values, and vital sign records showed no BPs taken to coincide with many Metoprolol doses over several days. Facility staff, including the NP, ADON, RNC, and DON, acknowledged that BPs should have been checked before giving antihypertensive medications, and the facility’s medication administration policy required verification of vital signs when necessary.
Surveyors found that two residents did not have comprehensive, person-centered care plans with measurable objectives and timeframes documented in their records, despite completed MDS assessments and a facility policy requiring such plans. One resident with hypertension and moderately impaired cognition and another receiving surgical aftercare with intact cognition both lacked comprehensive care plans in the electronic care plan tab. The MDS nurse reported she could not open care plans herself and relied on an RN or the DON to create them, and stated she had notified the team that these care plans needed to be opened. The DON confirmed that only certain RNs closed care plans, that baseline care plans existed for both residents, but that comprehensive care plans could not be located, and acknowledged responsibility for ensuring their completion.
A resident receiving post-surgical aftercare for a right foot wound did not receive wound care consistent with the facility’s infection prevention and control policies. During an observed treatment, an NP and a WCN donned only gloves instead of required gown and gloves under EBP, did not place a clean barrier between the wound and soiled linens, and the NP leaned over the wound with hair falling around the site. The WCN cleansed the wound from outer to inner areas, wiped the unclean bottom of the foot and then continued care without changing gloves or performing proper hand hygiene, and did not fully rub alcohol-based hand rub until dry. Contaminated trash was placed on a surface holding clean supplies, and a dirty treatment tray was carried through the facility to locate sanitizing wipes instead of being cleaned at the point of care, contrary to the facility’s EBP and hand hygiene policies.
A facility failed to ensure two residents received ordered BP checks before PRN BP-related meds. One resident had an order for Midodrine for hypotension, but BP was not monitored as directed and the med was not given. Another resident had an order for Lisinopril for hypertension, but BP was not recorded on multiple days to determine whether the med was needed. The DON and nursing staff acknowledged the ordered monitoring was not completed and could not explain why.
Kitchen Food Storage and Dishwashing Sanitation Failures: Surveyors observed an unclean ice machine, improperly labeled and dated food in the refrigerator, freezer, and dry storage areas, and multiple clean dishes that still had visible residue. The dishwashing area and machine also had limescale, food debris, and trash present, and the dish machine temp/sanitizing log was not completed for multiple wash cycles. Staff stated dishes were not being checked after washing and that some items should have been discarded or rerun.
Failure to Provide Privacy During Wound Care: A resident receiving wound care was observed with the room door left open while a WCN performed treatment, allowing other residents, staff, and visitors passing by to see the procedure. The WCN stated privacy was important during wound care and acknowledged the door was not closed, and the DON stated the care should have been kept private and confidential to protect the resident’s dignity and respect.
Failure to Change and Document Suprapubic Catheter Bag per Order: A resident with a suprapubic catheter, prostate cancer, and obstructive/reflux uropathy had a collection bag that remained dated from a prior change while staff gave conflicting accounts about when the bag was changed and documented. An LPN stated the bag change was not due yet, another nurse said she changed the catheter and bag but forgot to document part of the care, and the DON stated nurses were expected to follow the MD order and document care right away. The facility could not provide a urinary catheter policy when requested.
Medication Cart Left Unlocked: A surveyor observed Nurse Cart 1 with the top drawer slightly open at the nurse's station, and the drawer could be fully opened to access medications with no nurse present. RN E later identified the cart as hers and stated it should be locked when not in use; the DON also stated medication carts should be secured when not in use. The facility policy stated the cart and storage bins should be kept closed, secured, and/or in the line of sight when not in use.
Inaccurate Documentation of Suprapubic Catheter Care: An LVN documented that a resident’s suprapubic catheter collection bag was changed even though observations showed the bag still bore an older date. The resident had a suprapubic catheter for prostate cancer-related urinary issues, and the MAR entries conflicted with the actual condition of the bag. Interviews with the LVNs and DON showed confusion about when the care was completed and when it was documented, resulting in false charting of catheter care.
Failure to Perform Hand Hygiene During Wound Care: A resident with DM, CKD, COPD, heart disease, and MRSA at the LBKA site received wound care while the WCN repeatedly removed gloves without performing hand hygiene before, during, and after the procedure. The WCN acknowledged hand hygiene is needed after glove removal to prevent cross contamination, and the DON stated it is important to avoid possible cross contamination. The facility policy required hand hygiene before handling dressings, before moving from contaminated to clean care, after handling used dressings or contaminated equipment, and after glove removal.
The facility failed to meet professional standards for food service safety, with deficiencies in food storage, preparation, and cleanliness. Thermometers were missing from refrigerators and freezers, temperatures were not logged as required, and food items were improperly stored and labeled. The kitchen was infested with bugs, and utensils were hazardous. Expired food was found in resident nutrition rooms, and staff interviews revealed a lack of adherence to food safety protocols.
The facility failed to maintain an effective pest control program, resulting in live roaches in the kitchen. Observations revealed roaches on food preparation surfaces and clean dishware. Interviews indicated awareness of the issue and a crack in the ceiling, which had been noted but not repaired. Pest control measures were ineffective, with longstanding issues documented in work orders and invoices.
The facility failed to protect the privacy of two residents' medical information. A resident's lab results were left visible on a medication cart, and another resident's medical information was displayed on an unattended computer screen. Staff acknowledged these as HIPAA violations, emphasizing the importance of confidentiality.
A facility failed to provide written notification of transfer or discharge to a resident, their representative, and the Ombudsman. The resident, with multiple health issues, was transferred to the hospital without written notice, contrary to facility policy. Staff confirmed that only verbal notifications were given, especially in emergencies.
The facility failed to complete accurate PASRR evaluations for two residents with mental health diagnoses, leading to incorrect screenings that did not reflect their conditions. This oversight was acknowledged by the responsible RN, who attributed the errors to a previous employee. The facility's policy requires timely and accurate PASRR screenings to ensure residents receive necessary services.
A resident with severe cognitive impairment and multiple medical conditions experienced a fall resulting in injury. The facility failed to update the resident's care plan to include necessary fall precautions and interventions, despite the resident being on anticoagulant medications. Interviews with staff confirmed the oversight, highlighting a lapse in adhering to the facility's policy for updating care plans with significant changes.
Two residents with indwelling urinary catheters were observed with their catheter bags and tubing improperly positioned, leading to potential infection risks. One resident's catheter tubing was dragging on the ground, while another's catheter bag was resting on the floor. Staff interviews confirmed that such practices could lead to contamination and infection, highlighting a failure to adhere to the facility's care protocols.
A resident with COPD and emphysema was found self-administering nebulizer treatments and using leftover medication, contrary to physician orders requiring nurse administration every six hours. Despite staff awareness, there was no documented follow-up, and the resident continued accessing medication independently, indicating a lapse in the facility's medication administration procedures.
A resident with multiple health conditions was hospitalized after receiving Clonidine outside of physician-ordered parameters. The medication, intended for high blood pressure, was administered 166 times incorrectly due to a misinterpretation of the order as scheduled rather than PRN. This error was discovered after the resident exhibited low blood pressure, prompting a hospital transfer.
The facility did not promptly inform the physician about a resident's significant wounds upon admission, including skin tears and a pressure injury on the coccyx. This delay continued when the resident's wound worsened, leading to a lack of timely medical interventions. The facility's policy on Changes in Resident Condition mandates notifying the medical provider of significant changes, but staff interviews revealed communication and documentation discrepancies. This resulted in delayed physician notification and potential risks to the resident's health.
A resident with multiple wounds and complex medical conditions, including a displaced intertrochanteric fracture, rib fractures, muscle wasting, spinal stenosis, COPD, and malnutrition, did not receive a thorough head-to-toe assessment upon admission. This led to a failure to accurately identify, describe, and document wounds. Wound care orders were delayed by 11 days, and there was no consultation with the physician to reconcile hospital discharge wound treatment orders. Inconsistent documentation and lack of timely care plan updates were noted, along with gaps in communication and assessment practices among nursing staff. These issues highlighted systemic problems in wound management, assessment, documentation, and communication processes.
The facility failed to develop and implement a comprehensive care plan for a resident with multiple medical conditions, including surgical wounds, oxygen therapy, fall risk, and pain. The care plan was not updated when the resident's condition worsened, leading to potential risks for the resident.
The facility failed to develop and implement a comprehensive care plan for a resident, neglecting to address surgical wounds, oxygen therapy, fall risk, and pain management. Despite the resident's multiple medical conditions and documented needs, the care plan lacked necessary interventions, leading to inadequate care planning.
Infection Control Lapse During Incontinent Care
Penalty
Summary
Provide and implement an infection prevention and control program was cited after an observation of incontinent care showed a CNA failing to maintain hand hygiene and glove changes during care for a resident with multiple chronic conditions, including COPD, chronic atrial fibrillation, chronic diastolic heart failure, and vascular dementia. The resident’s quarterly MDS documented a BIMS of 9, indicating severe cognitive impairment, and the resident was dependent on staff for ADLs. The care plan identified the resident as at risk for infection or recurrent/chronic infection related to compromised medical condition. During the observation, the CNA washed her hands, then used her gloved hands to close the curtain, pull back blankets, remove pillows, and roll down the brief before cleaning the resident’s perineal area. After cleaning the perineal area, the CNA turned the resident to the left side, removed the soiled brief, and cleaned the gluteal area, then applied a clean brief, all without changing gloves or performing hand hygiene. In interview, the CNA stated she did not change gloves after touching the resident’s curtain, blanket, and pillows, and was unaware she had to change gloves and perform hand hygiene when moving from the perineal area to the buttocks area. The ADON and DON stated the CNA should have removed her gloves and completed hand hygiene after touching the resident’s environment and before turning the resident to clean the buttock area.
Failure to Assess Blood Pressure Prior to Metoprolol Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to administration of an antihypertensive medication, Metoprolol. The resident was an [AGE]-year-old female with a diagnosis of essential primary hypertension, admitted on 02/24/2026 and discharged on 03/11/2026. A physician order dated 02/24/2026 directed Metoprolol 12.5 mg by mouth four times daily for hypertension, with instructions to hold the dose if the systolic blood pressure was less than 110 or the diastolic blood pressure was less than 60. The resident did not have a comprehensive care plan in place, and the March 2026 MAR reflected the Metoprolol order and administration times (9:00 AM, 12:00 PM, 5:00 PM, and 9:00 PM) but did not include corresponding blood pressure readings. Record review of the resident’s vital signs showed that blood pressures were not taken at times that coincided with Metoprolol administration on multiple dates in February and March 2026, despite the order requiring blood pressure parameters prior to dosing. Specifically, there were no blood pressure measurements documented at the scheduled administration times on numerous dates between 02/25/2026 and 03/10/2026. The RNC was only able to locate a few blood pressure readings in the MAR and vital signs that coincided with the Metoprolol doses, and those readings were associated with another medication being administered, not with Metoprolol. Interviews with facility staff confirmed that blood pressures should have been checked before administering the blood pressure medication. The NP stated that blood pressures should be checked prior to giving antihypertensive medications to determine if the resident actually needed the dose. The ADON stated that nurses should have checked blood pressures before administering the medication because it was required, and acknowledged that nurses had previously been in-serviced on this topic. The RNC and DON both stated that blood pressures should be assessed prior to administering blood pressure medications, and confirmed that only a few coinciding blood pressure readings could be found for this resident. The facility’s “Administering Medications” policy, revised April 2019, required that vital signs be checked or verified, if necessary, prior to administering medications, and external clinical guidance from the National Library of Medicine emphasized the importance of accurate blood pressure assessment for diagnosis and management of hypertension.
Failure to Develop and Implement Comprehensive Care Plans for Two Residents
Penalty
Summary
Surveyors identified a failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for two residents. For Resident #1, a female with essential primary hypertension admitted in late February and discharged in early March 2026, record review showed an admission MDS with a BIMS score of 09 (moderately impaired cognition), completed on 03/04/2026. However, review of the care plan tab on 03/18/2026 revealed there was no comprehensive care plan in the record. The facility’s policy required that the IDT, with the resident and/or representative, develop a comprehensive care plan within seven days of completion of the required MDS assessment. For Resident #2, a male with a diagnosis of encounter for surgical aftercare following circulatory system surgery and an original admission in mid-February with a readmission in early March 2026, review of the care plan tab on 03/19/2026 also showed no comprehensive care plan. His BIMS evaluation showed a score of 15, indicating intact cognition. In interviews, the MDS nurse stated that if there was no care plan under the care plan tab, one had never been opened or created, and reported she had mentioned in morning meeting that care plans for these residents needed to be opened because she could not open them herself. She explained that only one RN besides the DON could open or create a care plan and that she typically followed a three-day rule after admission to have comprehensive care plans opened. The DON stated that any IDT member could initiate or create a care plan but it was closed by the DON or another RN, and while he was able to locate baseline care plans for both residents, he could not find their comprehensive care plans and was unsure why they were not completed, acknowledging that responsibility for verifying completion rested with him.
Inadequate Infection Control During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program during wound care for Resident #2. Resident #2 was an adult male with an original admission date of 02/17/2026 and a current admission date of 03/06/2026, with a pertinent diagnosis of encounter for surgical aftercare following surgery on the circulatory system. Physician orders dated 03/09/2026 directed specific wound care to the right foot surgical site, including cleansing with Dakin’s solution, rinsing with normal saline, patting dry, applying adaptic and alginate AG, lightly packing the wound bed if needed, covering with an ABD pad, wrapping with Kerlix, and securing with tape. There was also an order to practice Enhanced Barrier Precautions (EBP) when in contact with the wound and/or PICC line. Record review showed Resident #2 did not have a comprehensive care plan in the electronic record. On 03/19/2026, during an observation of wound care, the Wound Care Nurse (WCN) and Nurse Practitioner (NP) performed multiple infection control breaches. After performing hand hygiene, both staff donned only gloves and did not put on disposable gowns before providing wound care, despite the EBP order and facility policy requiring gown and glove use for high-contact activities such as wound care. No clean barrier was placed between the resident’s right foot wounds and the dirty bed sheet. The NP leaned over the wound, allowing her hair to fall around the wound area. The WCN cleansed the wound from the outside to the inside, contrary to best practice and facility expectations to cleanse from the inner (cleanest) to outer (dirtiest) area. Additional lapses occurred in hand hygiene and handling of contaminated materials. After wiping the bottom of the resident’s unclean foot when medicated gel ran down, the WCN continued wound care without performing hand hygiene and changing gloves. She also did not rub alcohol-based hand sanitizer over all hand surfaces until dry between glove changes. The WCN placed trash from the wound care onto the same clean barrier used for clean wound care supplies, and then performed hand hygiene and donned clean gloves before picking up the dirty tray to clean it. She carried the contaminated tray through the facility in search of sanitizing wipes, as none were available on her cart, instead of immediately cleaning it at the point of care. Interviews with the NP, WCN, and ADON confirmed that appropriate PPE (gown and gloves), correct wound cleansing technique, proper hand hygiene, and correct handling of contaminated equipment and surfaces were expected per the facility’s Enhanced Barrier Precautions and Hand Hygiene policies, but were not followed during this wound care episode.
Missed Blood Pressure Monitoring Before PRN Antihypertensive and Midodrine Administration
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors for two residents who had physician orders requiring blood pressure monitoring before administration of blood pressure-related medications. One resident, a female with diagnoses including epilepsy, COPD, and type 2 diabetes, had an order for Midodrine HCl 5 mg every 12 hours as needed for hypotension, with instructions to give the medication if systolic blood pressure was less than 100. Her blood pressure log showed only two recorded blood pressures across August and September 2025, and the medication was not administered during those months. Staff interviews reflected that her blood pressure should have been checked twice daily to determine whether the medication was needed, but there was no explanation for why the assessments were not completed. A second resident, a female with peripheral vascular disease and a BIMS score of 11, had an active order for Lisinopril 10 mg every 24 hours as needed for hypertension, with instructions to give one tablet daily if blood pressure was above 140/90. Her blood pressure log showed multiple days in August and September 2025 when blood pressure was not recorded. Staff stated her blood pressure should have been checked at least once daily to determine whether lisinopril was needed, but the readings were not obtained on the missed days. The resident’s care plan included monitoring vital signs as indicated and administering medications as ordered. The DON stated both residents’ blood pressures should have been taken according to the orders and acknowledged there was no answer as to why the blood pressure assessments and medications were not given as prescribed. The facility policy on medication administration stated that vital signs or tests should be taken prior to administration of applicable medications and that medications should be administered as ordered by the physician. Interviews with nursing staff also reflected uncertainty about why the blood pressures were not being documented or trended as required.
Kitchen Food Storage and Dishwashing Sanitation Failures
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards in the kitchen. During the initial tour, the ice machine had black and rust-colored substances on the inside walls, lid, and hinge areas. A clear pitcher on a metal table had a white film inside it, and a tray near the microwave had a reddish spot on it while also holding wrapped silverware. Boxes of food items were observed on the floor in the kitchen area. The reach-in refrigerator contained multiple improperly stored items, including cream cheese in an opened and unsealed overwrap, smoked-sliced turkey breast in a partially opened zipper bag with unreadable original labeling, an opened and unlabeled container of sour cream, shredded cheese in opened and unlabeled bags with loose cheese in the bag, and unlabeled and undated bags containing sandwiches. The dry storage area contained opened or unsealed cereal and graham cracker crumbs, a sugar container with an unsecured lid and a beige chunk in the sugar, and a flour container with an unsecured and partially opened lid. The reach-in freezer contained an open cardboard box with frozen peanut butter cookies, an opened bag of onion rings, and an opened, unlabeled, and undated bag with an unknown breaded meat product. In the dishwashing area, a frying pan still had adhesive and an intact sticker on it, and a fine mesh strainer had brown and black buildup around the rim. A rack of clean dishes contained multiple bowls, cups, and plates with visible flecks, spots, chunks, streaks, and other residue, and one small porcelain plate had chips on the front edge. The automatic dishwashing machine had limescale buildup on the doors and inside edges, food chunks and trash under and around the machine, and food debris and wet packets on the clean and dirty side tables and dish trays. The dish machine temperature and sanitizing log was not completed for multiple wash cycles across several days, and staff stated dishes were not checked after washing and that dirty dishes would need to be run again if found unclean.
Failure to Provide Privacy During Wound Care
Penalty
Summary
The facility failed to ensure privacy for one resident during wound care. Resident #11 was a male with diagnoses including heart disease, type 2 diabetes, chronic kidney disease, and COPD, and his face sheet reflected an original admission date of 08/31/24. During an observation on 09/07/2025 at 4:19 PM, the WCN performed wound care in the resident’s room with the door left open, allowing other residents, staff, and visitors passing by to see the wound care being performed. During an interview on 09/07/2025 at 4:34 PM, the WCN stated privacy was important during wound care to maintain dignity and respect and acknowledged that not closing the door could make the resident feel shameful, sad, depressed, or less than. The WCN stated she did not realize she had not closed the door. In an interview on 09/08/2025 at 12:15 PM, the DON stated the WCN should have provided privacy during the wound care to ensure dignity and respect, and stated wound care should be confidential.
Failure to Change and Document Suprapubic Catheter Bag per Order
Penalty
Summary
The facility failed to ensure appropriate treatment and services were provided to prevent urinary tract infections for a resident with a suprapubic urinary catheter. Resident #49 was a male with diagnoses including prostate cancer, obstructive and reflux uropathy, urostomy with suprapubic urinary catheter, and difficulty walking. His care plan included catheter care every shift and as indicated, changing the catheter per physician order, and monitoring for signs and symptoms of infection. The physician orders included changing the suprapubic catheter monthly and changing the collection bag every 2 weeks and as needed. During observation on 09/07/25 and again on 09/08/25, the resident’s urinary collection bag was dated 08/16/25. The resident stated the night nurse had changed the catheter and collection tubing/bag in August and that the collection tubing/bag had not been changed in the previous week. LVN C stated the collection bag change was not due until 09/15, but when told the bag was dated 08/16/25, she stated she must have intended to change it but got busy and forgot to strike it out on the MAR. LVN D stated she changed the suprapubic catheter and collection tubing/bag on 08/16/25 and changed the collection tubing/bag again on 09/09/25, and she stated she documented the catheter change after midnight but forgot to document the collection tubing/bag change because it was not yet showing due. Interviews with nursing staff and the DON reflected that nurses were expected to follow physician orders for catheter and bag changes and document care immediately after it was done. LVN G stated she was not aware night shift did not change the urinary catheter collection tubing and bag on 09/01/25, and the DON stated that if the catheter and/or bag were not changed when ordered, it could cause infection and hospitalization. The facility was unable to provide a urinary catheter policy/procedure when requested, and the only related policy provided was the Professional Standard of Care policy.
Medication Cart Left Unlocked
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles for medications stored in 1 of 4 medication carts reviewed, specifically Nursing Cart 1. During an observation at 2:56 PM on 09/08/25, a state surveyor saw the top drawer of Nurse Cart 1 slightly open in front of the nurse's station on Wing 1 and was able to fully open the drawer and access medications with no nurse present. Approximately 45 seconds later, RN E approached the cart and stated that Nurse Cart 1 was hers. During an interview, RN E stated the medication cart should be locked when not in use and that keeping it locked was important so other people would not gain access to medications, ingest them, and have an adverse reaction. The DON also stated nurses should ensure their medication carts were locked when not in use. Record review of the facility policy titled Medication Cart Use & Storage, dated January 2023, stated the medication cart and its storage bins should be kept closed, secured and/or in the line of sight when not in use.
Inaccurate Documentation of Suprapubic Catheter Care
Penalty
Summary
The facility failed to maintain accurate medical records for one resident by documenting care that was not provided. Resident #49 had diagnoses including prostate cancer, obstructive and reflux uropathy, a suprapubic urinary catheter, and difficulty walking. His care plan included catheter care every shift and as indicated, changing the catheter per physician order, and monitoring for signs and symptoms of infection. The physician orders included changing the suprapubic catheter collection bag every 2 weeks and as needed. Record review showed LVN C documented on the September 2025 MAR that she changed Resident #49’s suprapubic catheter collection bag on 09/01/25. However, during observation on 09/07/25 and again on 09/08/25, the resident’s urinary collection bag was dated 08/16/25. The resident stated the night nurse changed the catheter and collection tubing/bag in August and that the collection tubing/bag had not been changed in the previous week. LVN C later stated the bag change was not due until the 15th of the month and then said she documented it because she changed it that day, but when told the bag was dated 08/16/25, she stated she must have intended to change it on 09/01/25, got busy, did not complete it, and forgot to strike it out on the MAR. Additional interviews showed LVN D stated she changed the suprapubic catheter and collection tubing/bag on 08/16/25 and again on 09/09/25, and that she documented the 08/16/25 catheter change on the MAR for 08/15/25 because it was after midnight. The DON stated nurses should follow physician orders for changing urinary catheters and collection tubing/bags and document care right after it was done. The facility stated it did not have a specific policy for nursing documentation, and provided a Professional Standard of Care policy stating licensed nurses should practice within applicable laws and follow written policies and procedures.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program for Resident #11 during wound care. Resident #11 was a [AGE]-year-old male admitted on 08/31/24 with diagnoses including heart disease, type 2 diabetes, chronic kidney disease, and COPD. His care plan identified him as at risk for infection or recurrent/chronic infection related to a compromised medical condition, and noted actual MRSA to the LBKA site. His physician orders included daily wound care for the RBKA and LBKA surgical wounds, including cleansing, packing, Santyl, hydrofera blue, and dry dressings. During an observation of wound care, the WCN repeatedly removed gloves without performing hand hygiene before, during, and after the procedure. Specifically, hand hygiene was not performed after removing gloves while preparing and setting up supplies, before beginning wound care, after cleansing the wound, after pat drying the wound, and after completing the wound care. In interview, the WCN stated hands need to be cleaned or washed after removing gloves to prevent cross contamination and acknowledged she was focused on the steps of the wound care and did not realize hand hygiene was not being performed between glove changes. The DON stated hand hygiene after glove removal was important to avoid possible cross contamination. The facility policy stated hand hygiene is the primary means to prevent the spread of infection and requires hand hygiene before handling dressings, before moving from contaminated to clean procedures, after handling used dressings or contaminated equipment, and before glove changes/after removing gloves.
Food Safety and Storage Deficiencies in Facility
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, resulting in multiple deficiencies in the storage, preparation, distribution, and serving of food. Observations revealed that the facility did not have thermometers in the reach-in refrigerators and freezers, nor in the dry storage room, as required by facility policy. Additionally, refrigerator and freezer temperatures were not recorded three times daily, as stipulated. Food and drink items were improperly stored, labeled, and dated, with some items found to be expired. Dirty eating utensils were placed on clean surfaces, and scoops were improperly stored inside containers. Cleaned dishes were found with food or beverage residue, and the kitchen area was infested with bugs. The kitchen's physical environment was also in disrepair, with ceilings and walls showing signs of damage. The kitchen area was not free of bugs, and serving utensils were found to be hazardous. Appliances and food preparation areas were not clean, and the dishwasher temperatures were not logged daily. These conditions posed a risk of food contamination and foodborne illnesses to residents. Interviews with staff revealed a lack of adherence to cleaning schedules and food safety protocols, with some staff unaware of the importance of proper food storage and labeling. In the resident nutrition rooms, expired food items were found, and some snacks were improperly stored and exposed to air. Staff interviews indicated a lack of clarity regarding responsibilities for checking expiration dates and ensuring proper storage. The facility's policies and procedures for food storage and safety were not consistently followed, leading to potential health risks for residents. The deficiencies were observed during a survey, highlighting significant lapses in the facility's food service operations.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of multiple live roaches in the kitchen. Observations on 08/14/24 revealed live roaches on the floor, food preparation surfaces, and clean dishware throughout the kitchen area. Specific instances included a live roach on a blue two-handled cup and several roaches on prep tables and the kitchen floor. Interviews with the Dietary Manager (DM) and Registered Dietitian (RD) indicated awareness of the pest issue and a crack in the ceiling of the dish room, which had been noted since 5/23/24 but remained unrepaired. The facility was on a twice-monthly pest control schedule, but the pest control measures appeared ineffective, as noted by the DM. The facility's work orders and pest control invoices revealed longstanding issues contributing to pest entry, such as openings at plumbing and electrical points, cracks along baseboards, and inadequate sealing of door levelers. These conditions had been documented in pest control invoices over several years, indicating a persistent problem with pest control management.
Privacy Breach of Residents' Medical Information
Penalty
Summary
The facility failed to ensure the privacy of residents' personal and medical records, resulting in two specific incidents involving Resident #33 and Resident #70. In the first incident, a printed sheet of paper containing Resident #70's laboratory values was left unsecured and visible to the public on a medication cart near the nurse's station. This occurred at 4:17 PM on 08/15/2024, with several residents present in the lobby area nearby. The sheet remained exposed for about one minute before RN A was informed of the situation. RN A acknowledged the presence of HIPAA-protected information on the paper and expressed concern about the potential embarrassment and disappointment Resident #70 might feel if he learned of the breach. In the second incident, RN A left a computer screen displaying Resident #33's personal medical information unattended while administering medication in Resident #33's room. This occurred at 8:13 AM on 08/16/2024, with the monitor facing the room and remaining on for approximately one minute. RN A admitted to accidentally leaving the screen on and recognized the information as HIPAA-protected. She expressed concern about the potential embarrassment and disappointment Resident #33 might experience if she became aware of the privacy breach. Interviews with other staff members, including LVN D, CNA E, the DON, and the ADM, confirmed that both incidents constituted HIPAA violations. They emphasized the importance of maintaining the confidentiality of residents' personal information and the potential mental distress that could result from such breaches. The facility's policy on resident rights also highlighted the right to have personal information kept confidential.
Failure to Provide Written Notification of Transfer or Discharge
Penalty
Summary
The facility failed to provide written notification of transfer or discharge to a resident, their representative, and the Office of the State Long-Term Care Ombudsman. This deficiency was identified for a resident who was transferred to the hospital due to acute kidney failure and a urinary tract infection. The facility's policy requires written notice of transfer or discharge, but in this case, only verbal notification was given to the resident's family representative. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that the facility's practice was to notify families verbally, especially in emergencies, without providing written documentation. The resident involved was an elderly male with multiple diagnoses, including unspecified dementia, Alzheimer's disease, end-stage renal disease with heart failure, and chronic kidney disease stage 4. The resident was transferred to the hospital and later returned to the facility. Despite the facility's policy stating that written notice should be provided and documented, the facility did not adhere to this requirement, as confirmed by interviews with the ADON, DON, and Administrator (ADM). The lack of written notification could potentially affect residents by limiting their access to advocacy services and appeal processes.
Failure to Complete Accurate PASRR Evaluations
Penalty
Summary
The facility failed to ensure that PASRR evaluations were completed for two residents, Resident #34 and Resident #3, either prior to or after their admission. Resident #34, a female with a diagnosis of schizoaffective disorder, was admitted and readmitted with active diagnoses of schizophrenia and depression. Despite these diagnoses, her PASRR Level 1 screening incorrectly indicated no evidence of mental illness. Similarly, Resident #3, who had multiple mental health diagnoses including major depressive disorder, schizophrenia, and bipolar disorder, also had an incorrect PASRR Level 1 screening that initially did not reflect her mental illness. The PASRR screenings for both residents were not conducted accurately, which was acknowledged by RN B, who was responsible for ensuring the screenings and referrals were completed. RN B admitted that the screenings were done incorrectly and should have been marked positive for mental illness. The error was attributed to a previous employee who conducted the initial screenings, and there was no clear answer as to why the mistakes occurred. The facility's policy requires PASRR screenings to be conducted within fourteen days of admission and when there is a significant change in the resident's condition. The facility's administration acknowledged that the admissions department initially held responsibility for the accuracy of PASRR screenings, but it was ultimately a team effort. The ADM and RN B both recognized that incorrect PASRR screenings could place residents at risk of not receiving necessary specialized services. The facility's policy emphasizes the importance of accurate pre-admission screenings to ensure residents receive the appropriate level and scope of services required by their medical and mental conditions.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, identified as Resident #41, which is consistent with the resident's rights and includes measurable objectives and timeframes. This deficiency was identified during a review of care plans for residents, where it was found that the care plan for Resident #41 was not updated following a fall with injury. The resident, who has severe cognitive impairment and requires assistance for all activities of daily living, experienced a fall on 08/11/24, resulting in a laceration and bruising. Despite the incident, the care plan was not revised to include updated fall precautions and specific interventions to prevent future falls. Resident #41 has a medical history that includes unspecified dementia, lack of coordination, osteoporosis, high blood pressure, muscle wasting, insomnia, overactive bladder, and abnormal gait. The resident is on anticoagulant medications, which increase the risk of bleeding and bruising. The care plan, dated 08/05/24, did not reflect the necessary updates following the fall, such as placing the bed in a low position, ensuring the call light is within reach, and using a scoop mattress and fall mat. These interventions were implemented after the fall but were not documented in the care plan. Interviews with facility staff, including the Assistant Director of Nursing (ADON), revealed that it is the responsibility of the nursing staff to update care plans to ensure the well-being of residents. The ADON acknowledged that Resident #41's care plan should have been updated to reflect the unwitnessed fall and the specific fall precautions and preventions. The facility's policy requires care plans to be updated with significant changes in conditions, but this was not adhered to in the case of Resident #41.
Inadequate Catheter Care Leads to Potential Infection Risk
Penalty
Summary
The facility failed to provide appropriate care for residents with indwelling urinary catheters, leading to potential risks of urinary tract infections. Resident #4 was observed with his catheter tubing dragging on the ground underneath his wheelchair in both the lobby and dining room areas. This improper handling of the catheter tubing was noted during multiple observations on the same day. Resident #4, who has severe cognitive impairment and requires a suprapubic catheter due to urinary retention, was not interviewable to provide further insight into the situation. Resident #70 was found with his catheter bag resting on the floor while lying in bed. Despite the resident's moderate cognitive impairment, he was able to communicate that the catheter bag was not usually on the floor and did not cause him discomfort. However, he did mention a previous leak in the bag that had been fixed. The care plan for Resident #70 included regular catheter care and monitoring for signs of infection, but the observation of the catheter bag on the floor indicates a lapse in adherence to these care protocols. Interviews with facility staff, including an LVN, CNA, DON, and ADON, confirmed that catheter bags and tubing should not be on the floor due to the risk of contamination and infection. Staff acknowledged the issue with Resident #4's catheter bag positioning and mentioned attempts to secure it more effectively, but these efforts were not successful. The facility's policies on routine resident care and infection prevention emphasize the importance of timely and proper catheter care, which was not upheld in these instances.
Failure in Medication Administration for Resident with Respiratory Conditions
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administering of medication for a resident with chronic respiratory conditions. The resident, who had a history of COPD, emphysema, and chronic respiratory failure, was observed self-administering nebulizer treatments and using leftover medication when experiencing shortness of breath. This practice was not in accordance with the physician's orders, which required the medication to be administered every six hours by a nurse. Interviews with staff revealed that the resident had been seen using the nebulizer independently, and although a CNA had informed a charge nurse about this, there was no follow-up action documented. The LVN confirmed that the medication was supposed to be locked up and administered by the charge nurse, and the resident was not authorized to self-administer medication. Despite this, the resident was able to access leftover medication, indicating a lapse in the facility's medication administration procedures. The Director of Nursing (DON) acknowledged the resident's independence and history of turning off the nebulizer during treatments. The DON stated that the resident was nearing the end of life and found comfort in having access to medication when needed. However, the facility's medication administration policy clearly stated that medications should not be left with residents unless they are approved for self-administration, which was not the case for this resident.
Medication Error Leads to Hospitalization
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of Clonidine. The resident, an elderly female with a history of heart failure, chronic kidney disease, dementia, and chronic obstructive pulmonary disease, was prescribed Clonidine to be administered only if her systolic blood pressure was greater than 160 and diastolic blood pressure was greater than 100. However, the medication was administered outside of these parameters a total of 166 times over several months by various staff members, leading to the resident being transferred to the hospital due to low blood pressure. The deficiency was identified when the resident was noted to appear different by staff, with a blood pressure reading of 84/45, prompting a transfer to the hospital. Interviews with staff revealed that the medication order was misinterpreted as a scheduled medication rather than PRN, leading to its administration outside of the prescribed parameters. The resident's physician confirmed that the medication should not have been given outside of the specified parameters, as it could cause adverse effects such as lightheadedness. The facility's investigation found that the medication order was transcribed in a confusing manner, contributing to the error. The system used by the facility only flagged specific instances when medication was held, which did not adequately highlight the repeated errors in administration. This oversight resulted in the resident receiving Clonidine inappropriately, which could have led to the adverse health event experienced by the resident.
Delayed Physician Notification for Wound Care Management
Penalty
Summary
The facility failed to immediately inform the physician of Resident #1's wounds upon admission, leading to a lack of timely and appropriate medical interventions. Despite the presence of significant wounds upon admission, including skin tears and a pressure injury on the coccyx, the facility did not consult with Resident #1's physician to reconcile the hospital discharge wound treatment orders for specific wound care instructions. This failure to notify the physician continued when Resident #1's worsening wound was discovered on 12/24/23, with the facility neglecting to inform the physician promptly. The lack of communication and action in notifying the physician of Resident #1's deteriorating wound condition could have placed the resident at risk of a decline in their condition, the need for hospitalization, or even death. The facility's policy on Changes in Resident Condition clearly outlined the importance of notifying the resident, assigned medical provider, and resident representative of significant changes in the resident's physical status or the need to alter treatment significantly. However, the facility's failure to adhere to this policy resulted in a situation where Resident #1's worsening wound condition was not promptly addressed. Interviews with staff revealed discrepancies in communication and documentation processes, with nurses failing to contact the physician promptly upon identifying changes in the resident's condition, specifically related to wound care. This breakdown in communication and adherence to established policies and procedures contributed to the deficiency identified during the survey. The deficiency identified in the facility's failure to immediately inform the physician of Resident #1's worsening wound condition highlights a critical lapse in patient care and communication processes. The lack of timely notification to the physician, despite clear policies in place, resulted in a delay in appropriate medical interventions for Resident #1. The interviews conducted with staff further emphasized the need for consistent and accurate documentation of resident conditions and timely communication with physicians to ensure resident safety and well-being.
Inadequate Wound Care and Documentation Practices
Penalty
Summary
The facility failed to ensure appropriate treatment and care for Resident #1, who was admitted with multiple wounds and various medical conditions, including a displaced intertrochanteric fracture of the right femur, left rib fractures, muscle wasting, spinal stenosis, COPD, and malnutrition. Upon admission, a thorough head-to-toe assessment was not conducted, leading to a failure to identify, describe, and document the wounds accurately. Wound care orders were not provided until 11 days after admission, and there was a lack of consultation with the physician to reconcile the hospital discharge wound treatment orders. The facility also did not consistently assess and document the progress of Resident #1's wounds, leading to a failure to develop appropriate treatment plans and goals specific to her conditions. Documentation inconsistencies were noted, with discrepancies between the admission skin assessment and subsequent nursing notes regarding the presence and description of wounds. The facility did not update Resident #1's care plan promptly when her condition worsened, indicating a lack of immediate response to changes in her health status. Interviews with staff revealed gaps in communication and assessment practices, with nurses failing to accurately assess, document, and communicate about Resident #1's wounds. The lack of timely and appropriate wound care could have placed Resident #1 at risk of infection, sepsis, hospitalization, or even death, highlighting the severity of the deficiency in care provided to her. The facility's policies on skin and wound management, care planning, and changes in resident condition were not consistently followed, as evidenced by the failure to conduct comprehensive assessments, update care plans promptly, and communicate effectively with physicians and interdisciplinary team members. The deficiency in providing appropriate treatment and care to Resident #1 exposed systemic issues in the facility's processes related to wound management, assessment, documentation, and communication. The lack of adherence to professional standards of practice and person-centered care principles resulted in a failure to meet Resident #1's medical needs and ensure her well-being during her stay at the facility.
Failure to Develop and Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #1, who was readmitted with multiple medical conditions including a displaced intertrochanteric fracture of the right femur, left rib fracture, and chronic obstructive pulmonary disease. Upon admission, Resident #1 had surgical and other wounds, was receiving oxygen therapy, and was at high risk for falls and pain. However, the care plan did not include objectives, goals, or interventions specific to these conditions, which were present upon her admission. Additionally, the facility did not update Resident #1's care plan when her condition changed, specifically when her wounds were found to be worse. The initial care plan created by the admitting nurse did not address surgical site care, skin or wound care, oxygen therapy, fall risk, or pain management. The MDS coordinator acknowledged that the care plans should be all-inclusive and specific to the resident's needs, and that any changes in condition should be documented and communicated to the interdisciplinary team. The facility's policies on care plans and changes in resident condition were not followed, as the care plan was not comprehensive and was not updated in a timely manner. This failure could place residents at increased risk of not having their individual needs met and decreased quality of life. The MDS coordinator admitted that the care plans were usually updated right away if there was a change in condition, but this did not occur in Resident #1's case.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident that included measurable objectives and time frames to meet the resident's medical, nursing, mental, and psychosocial needs. Specifically, the facility did not address and include objectives, goals, and interventions for the resident's surgical and other wounds, oxygen therapy, fall risk, or pain upon her admission. The resident had multiple medical conditions, including a displaced intertrochanteric fracture of the right femur, left rib fracture, muscle wasting, chronic obstructive pulmonary disease, and mild protein-calorie malnutrition. Despite these conditions, the care plan lacked necessary focus and interventions for her wounds, oxygen therapy, fall risk, and pain management. Upon admission, the resident's records indicated she had a clinical condition of respiratory disease and was receiving oxygen therapy. The initial skin assessment revealed non-pressure skin impairments, including skin tears and an incision/surgical wound, as well as a Stage 1 pressure injury on the coccyx. The resident also experienced acute and frequent pain in her back and right hip, which was relieved by medication and frequent position changes. Despite these documented conditions, the care plan did not include specific interventions for surgical site care, skin or wound care, oxygen therapy, fall risk, or pain management. The facility's MDS coordinator acknowledged that the initial care plans for new admissions were created based on the admitting nurse's assessment and that care plans were usually updated immediately upon a change in condition. However, the resident's care plan was not updated when her wounds worsened. The facility's policies required comprehensive care plans to be developed within seven days of the comprehensive assessment and to be updated with any changes in the resident's condition. The failure to adhere to these policies resulted in a lack of appropriate care planning for the resident's needs.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 138 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Portland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brookdale Trinity Towers | 8.6 mi | ★★★★★ | 11 | 0 |
| Alameda Oaks Nursing Center | 9.3 mi | ★★★★★ | 8 | 0 |
| Windsor Nursing And Rehabilitation Center Of Morga | 9.9 mi | ★★★★★ | 4 | 0 |
| Windsor Nursing And Rehabilitation Center Of Corpu | 10.7 mi | ★★★★★ | 10 | 0 |
| San Rafael Nursing And Rehabiliation | 12.3 mi | ★★★★★ | 12 | 2 |
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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.