Inspection Reports for
The Cedars Portland

Cedars Nursing Care Center is in substantial compliance with the National Fire Protection Association 101 Life Safety Code, 2012 Edition as referenced in 42 CFR 483.90 (a - d) - Physical Environment.

The facility failed to prohibit portable space heaters in patient rooms as required by the National Fire Protection Association, Life Safety Code, 2012 edition, sections 19.7.8 and 18.7.8. The administrator removed the portable heater prior to the surveyor's observation.

Cedars Nursing Care Center was determined to be in substantial compliance with 42 CFR 483, subpart B-Requirements for Long Term Care Facilities. No deficiencies were cited.

The facility was found deficient in multiple areas including failure to maintain resident dignity, inadequate housekeeping and maintenance, lack of baseline and comprehensive care plans, incomplete staff performance evaluations and education, unsanitary kitchen conditions, and inadequate staff competency in infection prevention and control.

The facility failed to conduct emergency preparedness training and testing annually and twice per year respectively, maintain clear locations of 2-hour separation walls, keep illuminated exit signage operational, maintain fire alarm and sprinkler system policies and procedures, ensure corridor doors resist smoke passage, and properly mark oxygen cylinder storage areas.

Cedars Nursing Care Center was determined to be in substantial compliance with 42 CFR 483, subpart B-Requirements for Long Term Care Facilities.

The facility was found deficient in multiple areas including inadequate housekeeping and maintenance, failure to implement and revise care plans appropriately, failure to follow physician orders, improper medication administration via feeding tubes, unsanitary respiratory care equipment, improper medication storage and labeling, food safety violations, lack of annual review of infection prevention policies, and failure to offer pneumococcal vaccination to a resident as per CDC guidelines.

Cedars Nursing Care Center is in substantial compliance with 42 Code of Federal Regulations Part 483.73 for Emergency Preparedness and the National Fire Protection Association 101 Life Safety Code, 2012 Edition.

The facility failed to ensure that a resident was free from an avoidable accident hazard by not removing a hot pack timely for 1 of 1 residents reviewed for accidents, resulting in a dime-sized blister on the resident's lower back.

The facility failed to ensure a resident was free from an avoidable accident hazard related to timely removal of a hot pack, resulting in a blister on the resident's back.

The Cedars Nursing Care Center was found to be in compliance with 42 CFR 483, Subpart B-Requirements for Long Term Care Facilities during the follow-up visit.

The complaint was anonymous and alleged that Resident #1 experienced emotional/mental abuse by CNA #1, including harsh treatment, rough care with hot water, and lack of privacy leading to embarrassment. The complaint was substantiated by interviews and review of facility communications. The facility failed to report the abuse to the State Survey Agency and did not conduct a thorough investigation. The LCSW and Rehab Unit Nurse Manager did not report the allegations, and the DON acknowledged the failures.

The facility failed to protect Resident #1 from emotional/mental abuse by staff, failed to timely report the abuse allegations to the State Survey Agency, and did not conduct a thorough investigation. The Licensed Clinical Social Worker and Rehab Unit Nurse Manager did not report the allegations, and the Director of Nursing acknowledged the failure to report and investigate. The facility removed the alleged staff member from Resident #1's care but did not suspend or investigate properly. The LCSW had not completed required annual abuse/neglect training.

The facility was found deficient in multiple areas including failure to ensure PRN antipsychotic medication orders met required time limits, expired medications not removed from medication rooms and carts, unsafe and unsanitary storage of frozen foods, failure to monitor chemical sanitizer levels in kitchen, and inadequate infection prevention and control program including lack of water management for Legionella.

The facility did not report complete COVID-19 data to the NHSN between 07/24/2023 and 07/30/2023 as required by CMS and CDC regulations, potentially causing more than minimal harm to residents.

Cedars Nursing Care Center was found to be in substantial compliance with 42 CFR 483, Sub-part B-Requirements for Long Term Care Facilities.

This plan of correction addresses deficiencies cited under rules F584, F656, F657, F693, F755, F812, and F883 from the survey completed in early April 2024.