Robison Jewish Health Center: Bathing Neglect - OR
The resident, admitted in May 2025 following a stroke, needed maximum assistance with a Hoyer lift and was dependent on staff for showering twice weekly according to their care plan. Instead, certified nursing assistants documented bathing as "not applicable" on at least five occasions between June and August.
Staff 25, a certified nursing assistant, told inspectors she marked bathing as "not applicable" on August 8 because "she wasn't able to find someone to help get Resident 4 up using the Hoyer and bathing was not provided." Another assistant, Staff 26, gave the same explanation for August 15, stating bathing wasn't completed "due to a lack of assistance from other staff."
The pattern extended back to June. Staff 24 documented three instances where he couldn't complete the resident's bathing "due to a lack of staff and Hoyer lifts not being available" on June 6, June 20, and June 26.
No evidence showed the facility provided make-up showers when the scheduled baths were missed.
A family member confirmed the neglect during the September inspection, stating the resident "was not provided assistance with showers twice weekly" as required by the care plan.
The registered nurse case manager wasn't surprised by the findings. Staff 3 told inspectors "she was not surprised Resident 4 was not bathed or showered on the above dates because the facility had difficulties with staffing."
The resident was no longer at the facility when inspectors arrived in September and couldn't be interviewed about the missed care.
Federal regulations require nursing homes to provide assistance with activities of daily living for residents who cannot perform them independently. Bathing is considered essential to maintaining hygiene and preventing skin breakdown, particularly for stroke patients with limited mobility who depend on mechanical lifts.
The inspection report shows a systematic failure rather than isolated incidents. Three different nursing assistants across three months documented the same problem: they couldn't find adequate staffing or functioning equipment to safely transfer and bathe a vulnerable resident.
When confronted with the findings on September 10, the facility's administrator and director of nursing services acknowledged that "residents should be bathed in accordance with their care plans and as needed." Their response came after months of documented bathing failures for a resident whose stroke had left them completely dependent on staff assistance.
The violation received a "minimal harm" rating from federal inspectors, though it placed residents at risk of unmet care needs. The facility's own staff admitted they were aware of chronic staffing problems that prevented basic care from being delivered as planned.
For stroke patients like Resident 4, regular bathing isn't just about cleanliness. It's essential for preventing infections, maintaining skin integrity, and preserving dignity. When nursing homes document care as "not applicable" because they lack staff or equipment, they're essentially admitting they cannot meet the basic needs of their most vulnerable residents.
The inspection occurred after a complaint was filed about conditions at the facility. Federal inspectors examined bathing records for three residents and found failures for one of them, suggesting the problem may have affected other residents requiring similar mechanical assistance.
Robison Jewish Health Center's own care plan acknowledged the resident needed twice-weekly showers with maximum assistance using a Hoyer lift. The facility's inability to provide this basic care over multiple months raises questions about whether other residents requiring mechanical assistance received adequate hygiene care.
The documented failures span the resident's final months at the facility, from June through August 2025. Each time bathing was marked "not applicable," it represented another day the resident went without the basic hygiene care their medical condition required and their care plan promised.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Robison Jewish Health Center from 2025-09-10 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
ROBISON JEWISH HEALTH CENTER in PORTLAND, OR was cited for neglect violations during a health inspection on September 10, 2025.
Instead, certified nursing assistants documented bathing as "not applicable" on at least five occasions between June and August.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.