Inspection Reports for Hillside Heights Rehabilitation Center
1201 Mclean Blvd., OR, 97405
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Inspection Report
Complaint Investigation
Capacity: 83
Deficiencies: 37
Dec 5, 2025
Visit Reason
State-compiled facility profile showing 10 inspections from 2021 to 2025 with deficiency history and enforcement actions.
Findings
Across multiple inspections from 2021 to 2025, the facility exhibited numerous deficiencies including failure to investigate abuse allegations, inadequate nursing competencies, insufficient RN and CNA staffing, failure to maintain safe and sanitary environment, and lapses in resident care plans and infection control. Many deficiencies were not corrected at the time of inspections, placing residents at risk for harm, unmet needs, and reduced quality of life.
Complaint Details
Multiple complaint investigations documented, including failure to investigate abuse allegations, failure to notify families of changes, and failure to follow up on complaints related to resident care and abuse.
Deficiencies (37)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| F0610 - Investigate/Prevent/Correct Alleged Violation: Failed to complete investigations for abuse allegations for residents. |
| F0689 - Free of Accident Hazards/Supervision/Devices: Bed brakes malfunctioning contributing to resident falls. |
| F0692 - Nutrition/Hydration Status Maintenance: Failed to provide adequate eating assistance and supervision. |
| F0770 - Laboratory Services: Failed to obtain required STI testing and timely lab results. |
| F0552 - Right to be Informed/Make Treatment Decisions: Failed to provide risk and benefit information for psychotropic medication. |
| F0578 - Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir: Failed to offer or review advance directives with residents. |
| F0584 - Safe/Clean/Comfortable/Homelike Environment: Resident rooms in disrepair and strong urine odors present. |
| F0695 - Respiratory/Tracheostomy Care and Suctioning: Failed to maintain respiratory equipment and administer oxygen as ordered. |
| F0726 - Competent Nursing Staff: Staff lacked competencies in infection control and insulin administration. |
| F0727 - RN 8 Hrs/7 days/Wk, Full Time DON: Failed to ensure RN coverage for required hours. |
| F0761 - Label/Store Drugs and Biologicals: Medication refrigerator temperatures not maintained; treatment carts unsecured; unlabeled insulin pens. |
| F0806 - Resident Allergies, Preferences, Substitutes: Failed to honor resident food preferences and provide menus. |
| F0812 - Food Procurement,Store/Prepare/Serve-Sanitary: Kitchen unclean, food improperly stored, and temperature logs missing. |
| F0880 - Infection Prevention & Control: Failed to clean glucometers properly and follow transmission-based precautions. |
| F0908 - Essential Equipment, Safe Operating Condition: Kitchen equipment (refrigerator door handle) not maintained. |
| F0580 - Notify of Changes (Injury/Decline/Room, etc.): Failed to notify family of resident change of condition and hospital transfer. |
| F0677 - ADL Care Provided for Dependent Residents: Failed to provide required assistance with activities of daily living. |
| F0684 - Quality of Care: Failed to follow physician orders and care plans for multiple residents. |
| F0686 - Treatment/Svcs to Prevent/Heal Pressure Ulcer: Failed to accurately assess and treat pressure ulcers. |
| F0687 - Foot Care: Failed to provide appropriate foot care for residents. |
| F0688 - Increase/Prevent Decrease in ROM/Mobility: Failed to provide range of motion services and care for contractures. |
| F0699 - Trauma Informed Care: Failed to provide trauma-informed care for residents with trauma history. |
| M0143 - Employees: Criminal Record Checks: Failed to complete background checks for newly hired staff. |
| M0180 - Nursing Services: Daily Staff Public Posting: Failed to post accurate staffing information. |
| M0182 - Nursing Services:Minimum Licensed Nurse Staff: Failed to maintain appropriate RN coverage. |
| M0183 - Nursing Services: Minimum CNA Staffing: Failed to meet minimum CNA staffing requirements. |
| F0582 - Medicaid/Medicare Coverage/Liability Notice: Failed to provide written notification of coverage changes to residents. |
| F0636 - Comprehensive Assessments & Timing: Failed to develop comprehensive assessments for residents. |
| F0641 - Accuracy of Assessments: Failed to accurately assess residents' conditions. |
| F0656 - Develop/Implement Comprehensive Care Plan: Failed to develop comprehensive care plans for residents. |
| F0657 - Care Plan Timing and Revision: Failed to revise care plans timely for residents. |
| F0730 - Nurse Aide Peform Review-12 hr/yr In-Service: Failed to complete required annual training and performance reviews for CNA staff. |
| F0740 - Behavioral Health Services: Failed to provide person-centered behavioral health care and timely address mood symptoms. |
| F0745 - Provision of Medically Related Social Service: Failed to provide medically related social services for behavioral and emotional needs. |
| F0756 - Drug Regimen Review, Report Irregular, Act On: Failed to follow up on pharmacy recommendations for medications. |
| F0758 - Free from Unnec Psychotropic Meds/PRN Use: Failed to ensure appropriate psychotropic medication use. |
Report Facts
Inspections on page: 10
Total deficiencies: 51
Total surveys: 10
Licensing violations: 20
Abuse violations: 0
Notices: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 2 | Director of Nursing (DNS) | Named in multiple findings related to investigations, nursing competencies, and infection control |
| Staff 1 | Administrator | Named in findings related to notification failures, staffing, and care plan oversight |
| Staff 13 | LPN | Named in nursing competency and infection control deficiencies |
| Staff 6 | CNA | Named in failure to assist resident with eating and verbal abuse findings |
| Staff 7 | Director of Social Services | Named in findings related to advance directives and care planning |
| Staff 33 | LPN | Named in background check deficiency |
| Staff 9 | Activities Director/Former Social Service Director | Named in behavioral health and trauma informed care findings |
| Staff 14 | LPN Unit Manager | Named in medication cart security and bed brake findings |
| Staff 18 | Maintenance Director | Named in bed brake and environmental findings |
| Staff 32 | Former Doctor of Nursing Practice | Named in laboratory services and infection control findings |
| Staff 31 | RN Unit Manager | Named in multiple care plan and quality of care findings |
| Staff 15 | LPN | Named in respiratory care and quality of care findings |
| Staff 24 | LPN | Named in wound care and quality of care findings |
| Staff 4 | Regional RN | Named in infection control findings |
| Staff 16 | Med Tech | Named in respiratory care findings |
| Staff 25 | CNA | Named in infection control and abuse findings |
| Staff 30 | Human Resources | Named in background check deficiency |
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