Inspection Reports for Advocate Care
13033 SOUTH EAST HOLGATE BLVD, PORTLAND, OR, 97236
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 2, 2025, identified multiple deficiencies related to resident monitoring, medication and treatment orders, psychotropic medication documentation, and fire drill records. Earlier inspections showed a pattern of issues including staffing tool implementation, kitchen sanitation, infection control, medication administration, and building maintenance. Inspectors cited recurring themes in resident health services, staffing adequacy, food sanitation, and safety systems. No fines, immediate jeopardy findings, or enforcement actions were listed in the available reports, and complaint investigations were not substantiated. The inspection history indicates ongoing challenges with regulatory compliance, with no clear trend of improvement or worsening over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
25% better than Oregon average
Oregon average: 6.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Re-licensure
Capacity: 34
Deficiencies: 5
Date: Apr 2, 2025
Visit Reason
Multiple deficiencies including failure to ensure residents were evaluated and monitored for changes of condition, incomplete documentation of interventions, failure to carry out medication and treatment orders as prescribed, inadequate documentation for psychotropic medications, and fire drill documentation deficiencies.
Findings
Multiple deficiencies including failure to ensure residents were evaluated and monitored for changes of condition, incomplete documentation of interventions, failure to carry out medication and treatment orders as prescribed, inadequate documentation for psychotropic medications, and fire drill documentation deficiencies.
Deficiencies (5)
OAR 411-054-0040 (1-2) Change of Condition and Monitoring — Change of Condition and Monitoring deficiencies merged
OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services — Resident Health Services deficiencies merged
OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders — Systems: Treatment Orders deficiencies merged
OAR 411-054-0055 (6) Systems: Psychotropic Medication — Systems: Psychotropic Medication deficiencies merged
OAR 411-054-0090 (1-2) Fire and Life Safety: Safety — Fire and Life Safety: Safety deficiencies merged
Inspection Report
Complaint Investigation
Capacity: 34
Deficiencies: 2
Date: Feb 28, 2025
Visit Reason
Failure to fully implement and update an acuity-based staffing tool, resulting in staffing levels not meeting required acuity needs.
Findings
Failure to fully implement and update an acuity-based staffing tool, resulting in staffing levels not meeting required acuity needs.
Deficiencies (2)
Staffing Requirements and Training: Staffing — Staffing deficiencies merged
Acuity Based Staffing Tool - Updates & Plan — Acuity Based Staffing Tool deficiencies merged
Inspection Report
State Licensure
Capacity: 34
Deficiencies: 2
Date: Jun 11, 2024
Visit Reason
Kitchen sanitation issues including food spills, dated food items, damaged equipment, and poor maintenance; some issues corrected by revisit.
Findings
Kitchen sanitation issues including food spills, dated food items, damaged equipment, and poor maintenance; some issues corrected by revisit.
Deficiencies (2)
Resident Services Meals, Food Sanitation Rule — Food Sanitation deficiencies merged
Comment — Kitchen inspection comments merged
Inspection Report
State Licensure
Capacity: 34
Deficiencies: 2
Date: Jun 7, 2023
Visit Reason
Kitchen sanitation issues including dust accumulation, improper storage, uncovered lights, and lack of hair restraints; some issues corrected by revisit.
Findings
Kitchen sanitation issues including dust accumulation, improper storage, uncovered lights, and lack of hair restraints; some issues corrected by revisit.
Deficiencies (2)
Resident Services Meals, Food Sanitation Rule — Food Sanitation deficiencies merged
Comment — Kitchen inspection comments merged
Inspection Report
Re-licensure
Capacity: 34
Deficiencies: 9
Date: Feb 7, 2022
Visit Reason
Multiple deficiencies including infection control lapses, unclear service plans, medication administration inaccuracies, fire and life safety training deficiencies, building maintenance and repair issues, heating and ventilation problems, and door alarm system failures; some issues corrected on revisits.
Findings
Multiple deficiencies including infection control lapses, unclear service plans, medication administration inaccuracies, fire and life safety training deficiencies, building maintenance and repair issues, heating and ventilation problems, and door alarm system failures; some issues corrected on revisits.
Deficiencies (9)
Reasonable Precautions — Infection control and safety deficiencies merged
Service Plan: General — Service plan deficiencies merged
Medication Administration — Medication administration deficiencies merged
Fire and Life Safety: Safety — Fire and life safety deficiencies merged
Inspections and Investigation: Insp Interval — Inspection interval deficiencies merged
General Building Exterior — Building exterior maintenance deficiencies merged
Doors, Walls, Elevators, Odors — Building interior and odor control deficiencies merged
Heating and Ventilation — Heating and ventilation deficiencies merged
Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable — Door alarm system deficiencies merged
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