Inspection Reports for Friendship Health Center
3320 SE Holgate Blvd, Portland, Multnomah County, OR 97202, OR, 97202
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Inspection Report
Complaint Investigation
Capacity: 100
Deficiencies: 36
Nov 12, 2025
Visit Reason
State-compiled facility profile showing 10 inspections from 2023-11 to 2025-11 with detailed deficiency history and enforcement notices.
Findings
Across multiple inspections, the facility exhibited numerous deficiencies including failure to provide timely and accurate care, inadequate infection control, medication errors, incomplete discharge summaries, and failure to ensure resident rights and safety. Several deficiencies were not corrected at follow-up visits, indicating ongoing compliance challenges.
Complaint Details
Multiple inspections were complaint investigations, including findings related to failure to report COVID-19 data, failure to provide timely therapy, and failure to ensure resident rights and safety.
Deficiencies (36)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| M0000 - Initial Comments |
| F0686 - Treatment/Svcs to Prevent/Heal Pressure Ulcer: Failed to assess and conduct weekly wound evaluations for pressure ulcer care for 1 of 3 sampled residents. |
| M9999 - STATE OF OREGON ADMINISTRATIVE RULES: Refer to F686 |
| F0550 - Resident Rights/Exercise of Rights: Failed to ensure dignified language was used to address residents and their equipment for 1 of 2 sampled residents. |
| F0552 - Right to be Informed/Make Treatment Decisions: Failed to obtain consents for psychotropic medications for 2 of 6 sampled residents. |
| F0561 - Self-Determination: Failed to honor a resident's preference for room layout for 1 of 2 sampled residents. |
| F0578 - Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir: Failed to ensure residents had an advance directive for 2 of 4 sampled residents. |
| F0580 - Notify of Changes (Injury/Decline/Room, etc.): Failed to notify emergency contact of hospitalization for 1 of 2 sampled residents. |
| F0582 - Medicaid/Medicare Coverage/Liability Notice: Failed to provide required NOMNC and SNF ABN notifications to sampled residents. |
| F0584 - Safe/Clean/Comfortable/Homelike Environment: Failed to provide a homelike environment and maintain facility environment. |
| F0585 - Grievances: Failed to ensure a system was in place to resolve resident grievances promptly for 1 of 1 resident. |
| F0625 - Notice of Bed Hold Policy Before/Upon Trnsfr: Failed to provide bed hold policy to residents when transferred to hospital for 2 of 2 sampled residents. |
| F0641 - Accuracy of Assessments: Failed to accurately assess residents for communication, dental, and transfers for 3 of 9 sampled residents. |
| F0657 - Care Plan Timing and Revision: Failed to revise care plans to accurately reflect needs for 4 of 13 sampled residents. |
| F0676 - Activities Daily Living (ADLs)/Mntn Abilities: Failed to provide appropriate treatment and services in communication for 1 of 4 sampled residents. |
| F0677 - ADL Care Provided for Dependent Residents: Failed to provide necessary care and services to maintain personal hygiene for 1 of 5 sampled residents. |
| F0679 - Activities Meet Interest/Needs Each Resident: Failed to provide ongoing program to support individual activity interests for 4 of 4 sampled residents. |
| F0684 - Quality of Care: Failed to assess residents' change of condition timely; immediate jeopardy situation resulting in delayed treatment and death of a resident. |
| F0688 - Increase/Prevent Decrease in ROM/Mobility: Failed to provide restorative services and prevent decrease in range of motion for 4 of 10 sampled residents. |
| F0689 - Free of Accident Hazards/Supervision/Devices: Failed to ensure residents were free from accident hazards for 3 of 6 sampled residents. |
| F0742 - Treatment/Srvcs Mental/Psychoscial Concerns: Failed to provide treatment and services to correct ongoing depressive behavior for 1 of 1 sampled resident. |
| F0755 - Pharmacy Srvcs/Procedures/Pharmacist/Records: Failed to obtain and provide routine medication for 2 of 5 sampled residents. |
| F0758 - Free from Unnec Psychotropic Meds/PRN Use: Failed to monitor resident for side effects of antidepressants for 1 of 5 sampled residents. |
| F0759 - Free of Medication Error Rts 5 Prcnt or More: Medication administration error rate was 19.23%, exceeding 5% threshold. |
| F0761 - Label/Store Drugs and Biologicals: Failed to ensure medications and biologicals were secured and accessible only to authorized personnel for 5 of 6 halls observed. |
| F0791 - Routine/Emergency Dental Srvcs in NFs: Failed to ensure follow-up dental exam was scheduled for 1 of 4 sampled residents. |
| F0812 - Food Procurement,Store/Prepare/Serve-Sanitary: Failed to ensure foods were labeled and stored properly in kitchen. |
| F0825 - Provide/Obtain Specialized Rehab Services: Failed to ensure residents received timely specialized rehabilitative services for 1 of 1 sampled resident. |
| F0847 - Entering into Binding Arbitration Agreements: Failed to ensure residents were fully informed and understood binding arbitration agreements. |
| F0880 - Infection Prevention & Control: Failed to clean community use CBG monitors properly, implement enhanced barrier precautions timely, transport linens sanitarily, and ensure legionella water management plan. |
| F0884 - Reporting - National Health Safety Network: Failed to report complete COVID-19 information to CDC's NHSN during required period. |
| F0661 - Discharge Summary: Failed to complete discharge summary with required wound care and infection information for 1 of 1 sampled resident, resulting in wound worsening and hospital readmission. |
| F0695 - Respiratory/Tracheostomy Care and Suctioning: Failed to follow physician orders and provide correct oxygen administration for 1 of 3 sampled residents. |
| F0726 - Competent Nursing Staff: Failed to ensure licensed nursing staff possessed competencies necessary for oxygen administration for 1 of 3 sampled residents. |
| F0921 - Safe/Functional/Sanitary/Comfortable Environ: Failed to ensure wheelchairs were clean and sanitary for 1 of 3 sampled residents. |
Report Facts
Inspections on page: 10
Total deficiencies: 33
Licensing violations: 10
Notices: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Administrator | Named in multiple findings including dignified language, binding arbitration, infection control, and therapy authorization |
| Staff 2 | DNS (Director of Nursing Services) | Named in multiple findings related to wound care, medication errors, infection control, therapy authorization, and notification failures |
| Staff 5 | Bookkeeper | Responsible for providing information on binding arbitration agreements |
| Staff 9 | Social Services Coordinator | Named in findings related to resident rights, notifications, and beneficiary notices |
| Staff 17 | Social Services Director | Named in findings related to communication, grievances, dental services, and activities |
| Staff 21 | Director of Therapy | Named in findings related to therapy authorization and restorative services |
| Staff 25 | LPN | Named in findings related to wound care and discharge summary |
| Staff 29 | LPN | Named in findings related to wheelchair cleanliness |
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