Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Portland Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with chronic respiratory failure and CHF, who required one-to-one supervision during meals for aspiration precautions, was found alone with a partially eaten meal and no staff present. The speech therapist confirmed the lack of supervision, and the assigned CNA was unaware of the resident's care plan interventions.
The facility failed to timely assess and address changes in condition for two residents with skin conditions. One resident experienced significant pain and untreated fractures due to delayed response to reports of pain and injury. Another resident had untreated self-inflicted scratches and scabs, which were not reported to the physician or treated as required. The facility did not monitor or document the condition of the wounds, leading to inadequate care.
The facility failed to adequately assess and revise care plans for fall prevention, resulting in multiple incidents involving three residents. One resident, admitted with a history of falls, experienced several falls and was hospitalized, ultimately passing away. Another resident with frequent falls and impaired cognition had multiple non-injury falls, with care plan interventions not consistently followed. A third resident fell out of bed, and temporary safety measures were not implemented while awaiting a perimeter mattress. The facility's failure to implement timely and effective fall prevention measures placed residents at risk for injury.
The facility failed to facilitate Resident Council meetings, as required by their policy, since March 2024. Despite the Activities Director's claim that residents were uninterested, the Resident Council president and other residents expressed a desire for meetings. The Administrator, who started in August 2024, confirmed the absence of meetings, relying on information from the previous DNS without further verification.
The facility failed to provide a qualified Activities Director, impacting residents' needs. The Activities Director, hired with minimal experience, received no training in developing or implementing programs for adults in a nursing facility. She relied on internet resources and lacked guidance on working with residents with dementia or communication difficulties. The Administrator and DNS confirmed the lack of training and were assisting her with activity ideas.
The facility did not complete annual performance reviews for five CNAs, hired between 2017 and 2023, as required. This lapse was confirmed by the Business Office Manager and the Administrator, placing residents at risk of care from potentially incompetent staff.
A facility failed to prevent cross contamination by storing clean laundry items on the soiled side of the laundry room. Staff responsible for housekeeping and laundry confirmed the improper storage, and the Business Office Manager overseeing these departments acknowledged the error. The facility administrator also recognized that clean linens should not have been stored on the dirty side.
The facility failed to ensure accurate assessments for three residents, leading to unmet care needs. A resident with chronic respiratory failure had unaddressed hearing impairments, another was inaccurately assessed as having teeth despite being edentulous, and a third resident was incorrectly coded as needing more assistance with eating than required. Staff confirmed these inaccuracies, and the MDS Coordinator acknowledged errors in the assessments.
A facility failed to conduct a PASARR Level II evaluation for a resident with serious mental illness indicators. Despite a positive Level I PASARR and ongoing behavioral issues, no Level II evaluation was completed. The Social Services Director lacked training on the PASARR process, and the facility administrator admitted the evaluation should have been conducted.
Two residents in a LTC facility were not provided with person-centered activities as required by their care plans. One resident, with cognitive impairments, was not engaged in exercise classes or one-to-one sessions, while another resident, enrolled in hospice care, did not receive personalized activities like listening to music or going outside. The activities director lacked training, and the facility acknowledged the need for improvement.
A resident with a history of pain and contracted fingers on the left hand did not receive timely pain management before wound care treatments, despite physician orders for PRN oxycodone. The resident and a family member reported that pain medication was often administered too late to be effective. Staff interviews revealed inconsistencies in pain management practices, with an LPN failing to offer medication before treatment, contrary to the DNS's expectations.
A resident with bipolar disorder, depression, and panic disorder did not receive necessary behavioral health care services. Despite increased depression and aggression, the facility failed to revise care plan interventions or refer the resident to an in-house psychiatrist. The resident remained isolated and expressed suicidal ideations, with staff acknowledging the inadequacy of interventions and monitoring.
A resident in hospice care experienced delayed pain management due to ineffective communication between the facility and hospice provider. A fentanyl patch order was delayed by several days, and the patch was placed incorrectly on the resident's arm instead of the chest. Family and hospice staff reported ongoing communication issues, and facility staff were unaware of specific care instructions.
A resident, admitted for aftercare following surgical amputation and assessed as cognitively intact, overheard a former hospitality aide using a homophobic slur during a dinner service. The resident felt afraid and uncomfortable, fearing retaliation due to past experiences. Multiple staff members confirmed the incident, although the aide did not recall using the slur. The facility's investigation noted the resident was placed on alert monitoring for psychosocial well-being.
The facility failed to maintain a safe and comfortable environment, as a resident's bed mattress was found to be severely worn, making it difficult for the resident to move. Additionally, offensive odors, particularly of urine, were reported and observed in various areas, including bathrooms and hallways, with cracked tiles and inadequate sealing contributing to the issue. Staff confirmed the need for mattress replacement and repairs to address the odor problem.
A facility failed to ensure the correct POLST was available for a resident with chronic obstructive pulmonary disease, leading to a discrepancy in the resident's code status. The resident had two conflicting POLST documents, one indicating full code and the other DNR. Despite the resident's indication of wanting to be full code, staff confirmed the code status was inaccurately documented as DNR.
Failure to Provide Required Supervision for Aspiration Precautions
Penalty
Summary
The facility failed to implement care plan interventions for aspiration precautions for a resident with chronic respiratory failure and congestive heart failure. The resident's care plan required one-to-one supervision during all meals due to aspiration risk. On one occasion, the resident was found alone in their room with a partially eaten meal tray and no staff present, despite calling out for assistance. The speech therapist later confirmed the resident should have been under one-to-one supervision while eating and observed the meal tray unattended. The assigned CNA was unaware of the resident's need for supervised eating and stated it was their first shift working with the resident. The RCM also confirmed the resident's requirement for aspiration precautions and one-to-one supervision during meals.
Failure to Timely Address Changes in Condition and Skin Issues
Penalty
Summary
The facility failed to timely assess and address changes in condition for two residents with skin conditions, leading to significant pain and untreated injuries. Resident 8, who had a history of hemiplegia and hemiparesis following a stroke, experienced increased pain in the right knee and ankle, which was not promptly addressed. Despite multiple reports of pain and a confirmed diagnosis of fractures in the distal fibula and medial malleolus, there was a delay in providing adequate pain relief and in arranging for hospital evaluation. The resident reported significant pain and confirmed the injury occurred during a transfer, yet the facility did not act swiftly to address the resident's condition. Additionally, Resident 8's care plan required staff to monitor for changes in skin integrity, but a blackened toe was not reported in a timely manner. A CNA observed a red blister on the resident's toe but failed to report it immediately, leading to a delay in assessment and treatment. The facility's investigation acknowledged the failure to identify and address the skin issue promptly. Resident 22, admitted with a history of stroke, had multiple self-inflicted scratches and scabs on the upper extremities that were not evaluated or treated as per physician's orders. Despite observations by staff and complaints from the resident, the wounds were not reported to the physician or NP, and no treatment was implemented. The facility failed to monitor and document the condition of the wounds, resulting in a lack of appropriate care and intervention.
Inadequate Fall Prevention and Care Plan Revisions
Penalty
Summary
The facility failed to adequately assess and revise care plans for fall prevention, resulting in multiple incidents involving three residents. Resident 108, admitted with a history of falls and requiring supervision, experienced several falls within the facility. Despite being identified as high risk for falls, the care plan was not effectively revised following each incident. The investigations into these falls were delayed and incomplete, failing to identify and mitigate potential hazards. This lack of timely intervention and supervision led to Resident 108's hospitalization and subsequent death. Resident 40, with a history of frequent falls and impaired cognition, experienced multiple non-injury falls over several months. Although identified as high risk, the facility did not consistently implement or revise fall prevention strategies. Observations revealed that care plan interventions, such as keeping the wheelchair out of sight and engaging the resident in activities, were not consistently followed. Staff acknowledged the need for more thorough root cause analysis and intervention to prevent further falls. Resident 48, admitted with a traumatic subdural hemorrhage, fell out of bed, prompting the need for a perimeter mattress. However, temporary safety measures were not care planned or implemented while awaiting the mattress. Staff were unaware of the resident's fall risk status and recent incidents, indicating a lack of communication and adherence to care plans. The facility's failure to implement timely and effective fall prevention measures placed residents at risk for injury.
Failure to Facilitate Resident Council Meetings
Penalty
Summary
The facility failed to ensure that residents were provided with the opportunity to organize and participate in the Resident Council, as required by their policy. The policy, dated May 2002, stated that the Resident Council was intended to promote resident interest and involvement in the facility and serve as a forum for residents to voice concerns and suggest changes. The council was supposed to meet monthly or at a frequency determined by the council members. However, a review of the facility's Resident Council Minutes revealed that the last meeting occurred in March 2024, despite the facility having a census of 55 residents as of October 2024. Interviews with staff and residents indicated a lack of initiative to continue the Resident Council meetings. The Activities Director, hired in May 2024, stated that meetings did not occur because residents were not interested. However, the Resident Council president and other residents expressed a desire to have meetings, but none had been organized since the previous Activities Director left. The facility's Administrator, who started in August 2024, confirmed the absence of meetings and mentioned that he was informed by the previous Director of Nursing Services that residents were not interested, which he accepted without further verification.
Unqualified Activities Director Leads to Deficiency
Penalty
Summary
The facility failed to provide a qualified professional to direct the activities program, which affected the residents' physical, mental, and psychosocial needs. The facility's Key Personnel list identified Staff 14 as the Activities Director, who was hired in May 2024. Staff 14 admitted to having minimal experience and no training in developing or implementing an activities program for adults in a nursing facility. She relied on internet resources to develop the program and did not receive training on working with residents with dementia or communication difficulties. The previous administrator was supposed to enroll her in an activity training course, but this did not occur. The facility's Administrator and DNS confirmed that Staff 14 did not receive the necessary training and were assisting her with activity ideas until she could be trained.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to conduct annual performance reviews for five Certified Nursing Assistants (CNAs), which is a requirement to ensure competent staffing. Personnel records revealed that CNAs hired on various dates, ranging from 2017 to 2023, did not receive their mandatory annual performance evaluations. This oversight was confirmed by the Business Office Manager and the Administrator, who acknowledged that the expected annual reviews were not completed for these staff members. The lack of performance evaluations placed residents at risk of receiving care from potentially incompetent staff.
Improper Laundry Storage Leading to Cross Contamination Risk
Penalty
Summary
The facility failed to properly store laundry to prevent cross contamination, as observed during a tour of the laundry room. A metal rack containing clean towels, fabric room divider curtains, and sheets was found on the soiled side of the laundry room, covered partially by a cloth sheet held with metal binder clips, leaving the top uncovered. Staff 26, responsible for housekeeping and laundry, confirmed that these items were new and clean but acknowledged that they were improperly stored on the soiled side. This improper storage was confirmed by Staff 11, the Business Office Manager overseeing housekeeping and laundry, who recognized that clean items should not be stored on the soiled side. The facility administrator also acknowledged the error, stating that the clean linens should not have been stored on the dirty side.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure accurate assessments for three residents, leading to unmet care needs. Resident 14, admitted with chronic respiratory failure, was found to have impaired hearing that was not accurately captured in the MDS assessment. Despite being cognitively intact, Resident 14 struggled to hear staff and other residents, and there were no interventions in place to address this issue. Staff members confirmed the resident's hearing difficulties, and the MDS Coordinator acknowledged the oversight in the assessment. Resident 45, admitted with gram-negative sepsis, was inaccurately assessed as having teeth, despite being edentulous. The resident reported not being assessed for swallowing and expressed dissatisfaction with the soft food provided, as they were accustomed to eating regular food at home. Staff confirmed the resident's edentulous status, and the MDS Coordinator admitted to a coding error. Additionally, Resident 22, who had a stroke, was inaccurately coded as requiring supervision or touch assistance with eating, whereas they only needed set-up assistance. Staff confirmed the resident's ability to eat independently after receiving set-up help, highlighting the inaccuracies in the MDS assessment.
Failure to Complete PASARR Level II Evaluation
Penalty
Summary
The facility failed to complete a PASARR Level II evaluation for a resident who had a positive Level I PASARR indicating serious mental illness. The resident, admitted in November 2022, had diagnoses including bipolar disorder, depression, and panic disorder. The initial PASARR Level I conducted on November 9, 2022, identified indicators of serious mental illness, but no Level II evaluation was completed. The resident's condition included increased depression and behaviors such as verbal and physical aggression, swearing, and resisting care, as noted in subsequent evaluations and care plans. Despite these indicators, a second PASARR Level I conducted on March 15, 2023, after a hospitalization, did not identify serious mental illness, and its accuracy was not verified. The resident's family member reported requesting a mental health evaluation multiple times without success. The Social Services Director admitted to lacking formal training on the PASARR process and was unaware of any actions taken following the initial Level I screen. The facility administrator acknowledged that a Level II evaluation should have been conducted following the initial screen.
Failure to Provide Person-Centered Activities
Penalty
Summary
The facility failed to provide an ongoing person-centered activity program for two residents, leading to a deficiency in meeting their psychosocial needs. Resident 40, who was readmitted with diagnoses including diabetes and metabolic encephalopathy, had a care plan that emphasized the need for activities such as exercise classes and one-to-one sessions. Despite these requirements, observations and staff interviews revealed that Resident 40 was not engaged in group or one-to-one activities, and the activities director admitted to a lack of training and experience in developing suitable programs for the resident. Similarly, Resident 48, who was admitted with a traumatic subdural hemorrhage and was enrolled in hospice care, expressed preferences for activities like watching television, listening to music, and going outside. However, the resident's activity logs showed no participation in group activities or one-to-one visits. Staff interviews indicated a lack of awareness of the resident's interests, and the activities director confirmed that no personalized activities were offered to Resident 48. The deficiency was further highlighted by the activities director's acknowledgment of not having developed enhanced activity programs for the residents and the administrator's admission of the need for improvement in this area. The lack of personalized activities for both residents placed them at risk of a decline in psychosocial well-being and diminished quality of life.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide appropriate and timely pain management for a resident with a history of right upper quadrant pain, low back pain, and arthritis. The resident was observed to have contracted fingers on the left hand, which were painful to move. Despite physician orders directing the administration of PRN oxycodone 30 minutes to an hour before wound care treatment, the resident reported that pain medication was often given just prior to or even after the treatment, which did not allow sufficient time for the medication to take effect. This was corroborated by a family member who expressed concerns about the timing of pain medication administration. Staff interviews revealed inconsistencies in pain management practices. A CNA acknowledged the resident's complaints of pain and took care when assisting with personal care. However, an LPN stated that she did not offer pain medication prior to treatment because the resident did not complain about pain. During an observation, the resident expressed distress and demanded pain medication before treatment. The DNS stated that nurses were expected to assess the resident's pain level and offer medication before treatments, indicating a failure to adhere to these expectations.
Failure to Address Behavioral Health Needs
Penalty
Summary
The facility failed to provide necessary behavioral health care services for a resident with a history of bipolar disorder, depression, and panic disorder. The resident, admitted in November 2022, exhibited increased depression and difficulty coping with stress, as noted in multiple evaluations. Despite being on risperdal for bipolar disorder, the resident's care plan interventions were not effectively reviewed or revised to address ongoing mood symptoms and behaviors. Observations and interviews revealed that the resident remained isolated in their room, did not participate in activities, and expressed unhappiness. Family members reported the resident's suicidal ideations to the facility, but no mental health evaluation was conducted. Staff members described the resident as verbally and physically aggressive, with no recent onset of these behaviors. The Social Services Director acknowledged the inadequacy of the behavior monitor in tracking mood symptoms and the lack of appropriate interventions for the resident's depression. The facility's failure to refer the resident to an in-house psychiatrist and the ineffective interventions in place contributed to the deficiency. Staff members, including the Social Services Director and LPN Resident Care Manager, recognized the resident's unhappiness and care refusals but did not take sufficient action to address these issues. The facility administrator confirmed that the resident's mood and behavioral needs were not fully addressed, highlighting a significant gap in the provision of necessary behavioral health care services.
Communication Breakdown with Hospice Leads to Delayed Pain Management
Penalty
Summary
The facility failed to establish an effective communication process with the hospice provider, resulting in unmet needs for a resident receiving hospice care. The hospice policy required a coordinated Plan of Care (POC) between the facility and hospice, with the hospice responsible for notifying the facility of changes in care. However, there was a delay in implementing a physician's order for a fentanyl patch, which was intended to manage the resident's pain. The order was given on October 1, 2024, but the patch was not applied until October 5, 2024. Additionally, the patch was placed on the resident's arm instead of the upper chest as directed, and this issue persisted despite communication from the hospice nurse. The resident, who was admitted with a traumatic subdural hemorrhage and was cognitively intact, experienced pain and was enrolled in hospice care. Observations revealed that the fentanyl patch was consistently placed on the resident's arm, contrary to the hospice's instructions. Family members and hospice staff reported communication issues and delays in implementing hospice orders. Staff members were unaware of the specific instructions regarding the placement of the fentanyl patch, indicating a breakdown in communication and adherence to the hospice care plan.
Resident Dignity Compromised by Staff's Use of Homophobic Slur
Penalty
Summary
The facility failed to ensure a resident was treated in a dignified manner and free from derogatory slurs. This deficiency involved a resident who was admitted in June 2023 with diagnoses including aftercare for surgical amputation and was assessed as cognitively intact. During a dinner service, the resident overheard a former hospitality aide using a homophobic slur in conversation with other staff members. The resident reported feeling afraid and uncomfortable at the facility due to this incident and expressed concerns about potential retaliation, having experienced similar issues in the past. The facility's investigation revealed that multiple staff members confirmed the use of the derogatory term by the former hospitality aide. The resident was placed on alert monitoring for psychosocial well-being following the incident, with no negative outcomes reported. Interviews with staff and the resident confirmed the occurrence of the event, although the former hospitality aide did not recall using the specific slur. The facility administrator stated an expectation for all residents to be treated with dignity and respect, free from homophobic slurs.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to ensure a safe and comfortable environment for its residents, as evidenced by the condition of a resident's bed mattress and the presence of offensive odors throughout the facility. A resident, admitted in 2010 with diagnoses including abnormal posture, cognitive deficits, and depression, was observed to have a bed mattress with a large divot covering approximately three-quarters of the mattress, making it difficult for the resident to move. Staff members, including CNAs and the Maintenance Director, confirmed the mattress was old, broken down, and needed replacement. Additionally, the facility was reported to have offensive odors, particularly of urine, in various areas, including residents' bathrooms and hallways. Complaints were received by the State agency regarding the cleanliness and odor issues. Observations confirmed the presence of strong urine smells in specific rooms and hallways, with cracked tiles and inadequate sealing around toilets contributing to the problem. Despite housekeeping efforts, the Maintenance Director and Administrator acknowledged the persistent odor issues and the need for repairs to address the cracked tiles and sealing problems.
Discrepancy in Resident's POLST and Code Status
Penalty
Summary
The facility failed to ensure the correct Physician Orders for Life-Sustaining Treatment (POLST) was readily available and accessible for a resident, leading to a discrepancy in the resident's code status. The resident, admitted in October 2023 with chronic obstructive pulmonary disease and cognitively intact, had two signed POLST documents with conflicting instructions. The POLST dated October 4, 2023, indicated the resident wished to be full code, while the POLST dated October 27, 2023, indicated a Do Not Resuscitate (DNR) status. A public complaint in June 2024 alleged the resident wanted to be full code, but the POLST was filled out incorrectly. Interviews with staff confirmed the resident's code status was documented as DNR, which was not accurate according to the resident's wishes. The discrepancy was confirmed by the Director of Nursing Services (DNS) on October 29, 2024.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
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Nursing homes near Portland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Menlo Park Post Acute | 0.6 mi | — | 14 | 0 |
| Gateway Care And Retirement | 1 mi | — | 0 | 0 |
| Marquis Mill Park | 1.1 mi | — | 13 | 0 |
| Glisan Post Acute | 1.1 mi | — | 11 | 0 |
| Rose City Nursing And Rehabilitation | 1.1 mi | — | 1 | 0 |
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