Above average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Lacamas Creek Post Acute during CMS and state inspections, most recent first.
A resident, assessed as cognitively intact, reported repeated sexual assaults and called 911, also expressing suicidal ideation. Despite this, key staff including the DON, Social Services Director, and Administrator were unaware of the allegation, and the DON confirmed it was not reported due to doubts about its credibility and the resident's history of hallucinations. This resulted in a failure to follow policy and regulatory requirements for timely reporting of abuse allegations.
A resident with a history of trauma and a mood disorder did not have trauma informed care integrated into their care plan. Staff interviews revealed a lack of awareness and unclear communication processes between mental health providers and facility staff, resulting in the omission of trauma informed interventions in the resident's care planning.
A resident with severe cognitive impairment and a legal guardian experienced ongoing right knee pain and emotional distress due to chronic osteoarthritis. Despite repeated documentation of pain and limited participation in physical therapy, the facility did not notify the guardian about treatment options or seek consent for pain management interventions, such as a cortisone injection, until nearly seven weeks after admission.
The facility did not obtain daily weights as ordered by physicians for two residents with heart failure, resulting in multiple missed weight checks without proper documentation or explanation in the nursing notes. The DON confirmed that daily weights should be taken as ordered.
A resident who was alert and oriented and had a Living Will and DNR order did not have documentation in their record showing that their advance directive was reviewed quarterly as required. The Social Services Director confirmed that such reviews should occur but could not find additional information regarding the resident's advance directive.
A resident who was alert and oriented experienced a gap of over 105 hours between bowel movements, but the facility did not initiate the required bowel protocol interventions after 72 hours as per policy. Review of records and staff interviews confirmed that the protocol was not followed, and no medication intervention was documented during the period of constipation.
A resident with severe cognitive impairment and an unstageable sacrococcyx pressure ulcer did not receive proper infection control during wound care. An LPN compromised the clean field by placing wound dressing packages on the bed and failed to cleanse the wound after a bowel movement before applying topical treatment, contrary to physician orders and facility protocol. The infection control nurse confirmed that wounds should be recleaned after incontinence care.
The facility failed to ensure accurate MDS assessments for three residents. One resident was on hospice care, but this was not reflected in the MDS. Another resident was incorrectly documented as receiving insulin, despite no diagnosis or orders for it. A third resident's use of bed rails was wrongly coded as a restraint, although they were used for mobility aid. Staff confirmed these discrepancies, indicating errors in the MDS assessments.
The facility failed to initiate bowel interventions for two residents as per their Bowel Management Policy, leading to significant delays in bowel movements. Despite the policy requiring action after three days without a BM, the protocol was not followed, and documentation was lacking. Staff interviews confirmed the absence of necessary documentation and adherence to the protocol, placing residents at risk for discomfort and health complications.
The facility did not complete an annual performance review for a Nursing Assistant, Staff G, who was hired in 2014. The Administrator confirmed the absence of the evaluation, which is required annually, potentially risking resident care quality.
The facility failed to ensure informed consent for arbitration agreements with two residents. One resident did not recall signing the agreement, and her daughter usually handled such matters. Another resident's POA stated she should not sign legal documents due to a lack of understanding. The Marketing Director admitted to not fully explaining the agreement, including the revocation clause.
A facility failed to ensure bed rails were securely fastened for a resident who was moderately cognitively impaired. The resident's care plan included the use of side rails for bed mobility. Observations revealed the left side bed rail was loose on two occasions, with significant movement. Staff indicated that nursing assistants and floor nurses were responsible for monitoring bed rails, and the Maintenance Director noted that a clip had popped out, causing the issue.
The facility failed to provide dementia training to a Nursing Assistant, Staff G, who had been employed since 2014. Training records showed that Staff G did not complete dementia training in the past year, which was confirmed by the Staff Training Coordinator. The Administrator acknowledged the oversight, stating that Staff G should have received the training.
The facility failed to administer prescribed medications to two residents, including critical medications for heart conditions, hypertension, and pain management. There were no progress notes explaining the omissions, and the Director of Nursing Services confirmed the lack of documentation.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of sexual abuse for one resident. According to the facility's policy, all reports of resident abuse, neglect, exploitation, or theft are to be reported to appropriate authorities and thoroughly investigated. Documentation in the electronic health record showed that a resident, who was cognitively intact according to the most recent MDS, reported to a nurse that someone had been entering her room at night and alleged repeated sexual assaults over a nine-month period. The resident also called 911 to report these allegations and expressed suicidal ideation. Despite this, key staff members, including the Social Services Director, Resident Care Manager, and Administrator, were unaware of the allegation, and the Director of Nursing confirmed that the facility did not report the allegation because they did not believe it was real, citing the resident's history of hallucinations and the lack of a staff member matching the description provided. The failure to report the allegation was confirmed through interviews with multiple staff members, who indicated that such concerns would typically be communicated during meetings or directly by staff. The Administrator acknowledged not being aware of the allegation and attributed the lack of reporting to the resident's history of hallucinations. The Director of Nursing stated that the allegation was not reported because it was not considered credible. This lack of timely reporting was in direct violation of the facility's policy and regulatory requirements.
Failure to Integrate Trauma Informed Care into Resident Care Plan
Penalty
Summary
The facility failed to integrate trauma informed care into the care plan for one resident who was admitted for rehabilitation following hospitalization. Documentation showed that the resident was cognitively intact and had a history of trauma from adolescence into adulthood, as well as a mood disorder that warranted evaluation for mental health services. Despite this, a review of the electronic health record revealed there was no care plan addressing trauma informed care for this resident. Interviews with facility staff, including the Social Services Director, Resident Care Manager, and Director of Nursing, indicated a lack of awareness regarding the resident's trauma history and mental health needs. Staff were uncertain about how mental health providers communicated relevant information to the facility and how such information should be incorporated into the resident's care plan. As a result, the resident's trauma history and mental health concerns were not addressed in their care planning process.
Failure to Notify Guardian of Significant Change in Treatment for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to notify the legal guardian of a resident with severe cognitive impairment and a legal guardian regarding significant changes in treatment options for ongoing right knee pain due to chronic osteoarthritis. The resident, who had a BIMS score of 00/15 indicating severe cognitive impairment, repeatedly expressed pain and emotional distress related to her right knee. Despite multiple medical evaluations and documentation of her ongoing pain and inability to participate fully in physical therapy, the facility did not contact the guardian to discuss or obtain consent for potential pain management interventions, such as a cortisone injection, for nearly seven weeks after admission. Throughout this period, medical records show that the resident was offered a cortisone injection several times but declined due to fear of needles and limited understanding of the procedure, as noted by her providers. The lack of timely notification to the guardian meant that alternative consent for pain management was not pursued, and the resident continued to experience pain and emotional distress. Documentation of guardian notification and consent for the injection was not present until a progress note dated almost seven weeks after admission.
Failure to Obtain Daily Weights per Physician Orders for Residents with Heart Failure
Penalty
Summary
The facility failed to follow physician orders for obtaining daily weights for two residents diagnosed with heart failure. For one resident with severe cognitive impairment and congestive heart failure, the physician's order required daily weights to be taken in the morning before breakfast and after the first void, with instructions to notify the physician if certain weight gains occurred. However, there were three documented occasions when the resident was not weighed as ordered, and the Treatment Administration Record (TAR) indicated omissions with a chart code referencing nurses' notes. Upon review, there were no corresponding nurses' notes explaining the omissions on those dates. Similarly, another resident with heart failure and intact cognition had a physician's order for daily weights under the same protocol. There were six occasions when this resident was not weighed as ordered, with the TAR documenting chart codes for sleeping or referencing nurses' notes. Except for one note indicating the wheelchair scale was broken, there were no nurses' notes explaining the missed weights on the other dates. The Director of Nursing Services confirmed that daily weights should be taken as ordered, as the resident allows.
Failure to Review and Maintain Advance Directive Documentation
Penalty
Summary
The facility failed to provide assistance with completing advance directives and obtaining and maintaining Durable Power of Attorney (DPOA) documentation for one resident. The resident was admitted to the facility, was alert and oriented, and had a Living Will and Do Not Resuscitate (DNR) order documented in their social history assessment. However, a review of the resident's electronic record revealed there was no documentation that the advance directive had been reviewed on a quarterly basis as required. During an interview, the Social Services Director confirmed that advance directives are supposed to be reviewed quarterly and annually during care conferences, but could not locate any additional information regarding the resident's advance directive.
Failure to Initiate Bowel Protocol for Constipated Resident
Penalty
Summary
The facility failed to initiate bowel interventions as required by its own bowel protocol policy for a resident who experienced constipation. According to the facility's policy, licensed nurses are to monitor residents' bowel movements and initiate interventions if a resident has not had a bowel movement for three days. The policy specifies that after 72 hours without a bowel movement, the nurse should administer Milk of Magnesia, followed by a Dulcolax suppository if there is still no bowel movement by the next shift, and notify the physician if the period exceeds four days. For one resident, who was alert and oriented, documentation showed a gap of approximately 105.5 hours between bowel movements. Review of the Medication Administration Record did not show any medication intervention after 72 hours without a bowel movement. Interviews with nursing staff confirmed that the bowel protocol should have been initiated at the 72-hour mark, but it was not. This lapse was identified through record review and staff interviews, confirming that the facility did not follow its established protocol for bowel management.
Failure to Follow Infection Control Protocol During Wound Care
Penalty
Summary
A deficiency occurred when a licensed practical nurse (LPN) failed to implement proper infection control practices during wound care for a resident with an unstageable bilateral sacrococcyx pressure ulcer. The resident, who was severely cognitively impaired and dependent for activities of daily living, had physician orders specifying wound cleansing with normal saline or wound cleanser, treatment of the periwound area, application of anasept gel and collagen, and covering with a bordered dressing. During an observed wound care procedure, the LPN set up a clean field but moved wound dressing packages onto the resident's bed, which compromised the clean field. The LPN then opened the dressing packages and began wound care. While providing care, the resident had a bowel movement. The LPN provided incontinence care but proceeded to apply anasept gel to the wound bed without first cleansing the wound as required by protocol. When questioned, the LPN acknowledged the need to clean the wound after a bowel movement and subsequently did so. The infection control nurse confirmed that the expectation was for licensed nurses to maintain a clean field and reclean sacral wounds with normal saline or wound cleanser if a resident had a bowel movement.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the health status and care needs of three residents. Resident 39 was admitted for hospice care due to a terminal prognosis related to acute kidney failure, as documented in physician orders and the care plan. However, the Significant Change MDS assessment did not indicate that Resident 39 was receiving hospice care, despite confirmation from both the resident and staff that hospice services were being provided. This discrepancy was acknowledged by the Resident Care Manager, who admitted that hospice should have been marked on the MDS. Resident 41's Quarterly MDS assessment inaccurately documented that the resident received insulin injections, although there was no diagnosis of diabetes, physician orders for insulin, or a care plan for diabetes in the resident's Electronic Health Record. Both the resident and staff confirmed that Resident 41 was not on insulin, indicating an error in the MDS. Additionally, Resident 59's MDS assessment incorrectly coded the use of bed rails as a restraint, despite documentation and staff statements indicating that the rails were used to aid with bed mobility and were not considered restraints. The Director of Nursing Services confirmed that the MDS needed modification to accurately reflect the use of bed rails.
Failure to Initiate Bowel Interventions for Residents
Penalty
Summary
The facility failed to initiate bowel interventions for two residents, which was identified during a survey. According to the facility's Bowel Management Policy, a Licensed Nurse is required to review the Bowel Management Report at the beginning of each shift to identify residents who have not had a bowel movement (BM) for three days. The policy outlines a step-by-step protocol involving the administration of Milk of Magnesia, followed by a Dulcolax suppository, and then a Fleets enema if necessary. However, for Resident 5, there was a significant gap of over 15 days between documented BMs, and the bowel protocol was not initiated as per the Medication Administration Record (MAR). Similarly, Resident 32 experienced a gap of over 90 hours between BMs without the bowel protocol being initiated. Interviews with staff revealed a lack of documentation and adherence to the bowel management protocol. Staff K, a Registered Nurse, acknowledged the absence of documentation for the initiation of the bowel protocol for both residents and mentioned that such documentation should be present on the MAR. Staff B, the Director of Nursing Services, confirmed that the bowel management protocol should have been triggered according to the policy but was unable to provide evidence of its initiation for the affected residents. This oversight placed the residents at risk for discomfort and health complications, as noted in the report.
Failure to Conduct Annual Performance Review for Nursing Assistant
Penalty
Summary
The facility failed to complete performance reviews for one of the two sampled Nursing Assistants (NA), specifically Staff G. Staff G was hired on March 29, 2014, and their personnel records lacked a performance evaluation for the previous year. During an interview on September 26, 2024, the Administrator, Staff A, confirmed the absence of a performance evaluation for Staff G and acknowledged that such evaluations should be conducted annually. This oversight placed residents at risk of receiving care from unskilled staff.
Failure to Ensure Informed Consent for Arbitration Agreements
Penalty
Summary
The facility failed to adequately explain the arbitration agreement to two residents, leading to a deficiency in ensuring informed consent. Resident 28 signed the Alternative Dispute Resolution Agreement but later stated she did not recall signing it, indicating her daughter handled such matters. Similarly, Resident 46 signed the agreement but did not remember doing so, and her Power of Attorney (POA) confirmed that Resident 46 should not be signing legal documents due to a lack of understanding. The Marketing Director, Staff F, admitted to covering the arbitration agreement last during the admission process and was unaware of the revocation clause, suggesting a lack of comprehensive explanation to the residents or their representatives.
Failure to Securely Fasten Bed Rails
Penalty
Summary
The facility failed to ensure that bed rails were securely fastened to the bed and without gaps between the mattress and bed rails for one of the three sampled residents. Resident 22, who was moderately cognitively impaired, was admitted to the facility and had a care plan indicating the use of bilateral 1/4 side rails to aid in bed mobility and increase independence. On two separate occasions, the left side bed rail of Resident 22 was observed to be loose, with approximately 9 to 10 inches of movement. Staff I, a Resident Care Manager and Registered Nurse, stated that nursing assistants and floor nurses were responsible for monitoring bed rails and reporting issues to maintenance. Staff J, the Maintenance Director, mentioned that he attempted to audit bed rails every other week and identified that a clip had popped out, causing the bed rail to be loose.
Failure to Provide Dementia Training to Nursing Assistant
Penalty
Summary
The facility failed to ensure that staff received necessary dementia training, as evidenced by the case of Staff G, a Nursing Assistant hired on March 29, 2014. A review of training records revealed that Staff G had not completed dementia training in the past year. This oversight was confirmed during an interview with Staff H, the Staff Training Coordinator, who stated that dementia training is typically covered during new employee orientation and then annually. An email from Staff A, the Administrator, acknowledged the error, noting that Staff G, being a long-standing employee, should have received the training.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors when medications were not administered in accordance with provider orders for two residents. Resident 1, who was admitted with diagnoses including atrial fibrillation and hypertension, did not receive their prescribed doses of Apixaban and Metoprolol on a specified date. There were no progress notes explaining the omission of these medications, which are critical for managing the resident's heart condition and blood pressure. Similarly, Resident 2, who had multiple diagnoses including prostate cancer, hypertension, and gastro-esophageal reflux, did not receive several prescribed medications on a specified date. These medications included Amlodipine, Methadone, Omeprazole, Tamsulosin, Tizanidine, and MiraLAX. Again, there were no progress notes explaining why these medications were not administered. The Director of Nursing Services confirmed the lack of documentation for both residents' medication omissions, and the Administrator acknowledged the need to correct this practice.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 485 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Camas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Village Manor Of Cascadia | 3.5 mi | ★★★★★ | 1 | 0 |
| Marquis Centennial Post Acute Rehab | 5.5 mi | ★★★★★ | 14 | 0 |
| Avamere Rehabilitation Of Cascade Park | 5.6 mi | ★★★★★ | 9 | 0 |
| Fairlawn Health And Rehab Of Cascadia | 5.8 mi | ★★★★★ | 4 | 0 |
| Gresham Post Acute Care And Rehabilitation | 6.1 mi | ★★★★★ | 26 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Lacamas Creek Post Acute.
100% money-back within 48 hours.
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.