Robison Jewish Health Center: Care Failures Cited - OR
Federal inspectors cited the facility following a complaint inspection completed September 22, 2025, documenting how Resident 87's persistent itchiness moved through layers of staff without ever reaching the one person who could order a medical evaluation or change the resident's care.
The resident's complaints had been going on for months. One certified nursing assistant, Staff 37, told inspectors the resident had been scratchy for the past few months and believed it was an allergic reaction to the bedding. Staff 37 said all the nurses were aware of the itchiness and the possible allergy. When the resident was observed scratching, some nurses applied lotion. Nothing else was tried.
Staff 31, another CNA, said when he worked with Resident 87 the week before the inspection, the resident talked a lot about being itchy and allergic to the bedding. He did not report the concerns to anyone. His reason: the resident told him she/he had already reported it to upper management. So he let it go.
That assumption, repeated across multiple staff members, appears to be part of how the situation persisted. Each person who heard the complaint believed someone else had already handled it, or that the information had already traveled up the chain. It hadn't, not in any way that reached a physician.
Staff 29, a nurse, told inspectors she had reported the resident's concerns to Staff 38, the housekeeping and laundry supervisor. When inspectors spoke with Staff 38, she said she had been asked a few weeks earlier about the material of the facility's sheets but was never told those questions had anything to do with Resident 87 specifically. The concern arrived at housekeeping as a general inquiry and stopped there.
Staff 18, a licensed practical nurse, told inspectors she had personally observed Resident 87 itching and applied lotion when she did. She had not informed the resident's care manager or physician. She gave no explanation for why.
The administrator, Staff 1, told inspectors the physician should have been notified of the resident's itchiness as soon as it was observed.
That statement captures the gap. Inspectors documented the violation under F0684, which covers the standard of care residents are entitled to receive. The level of harm was cited as minimal harm or potential for actual harm, affecting some residents.
What the inspection report leaves unresolved is how long Resident 87's itching had actually been going on before someone filed a complaint that triggered the inspection. Staff 37 said months. The CNAs who interacted with the resident in the days before the inspection described a person who had been raising this concern repeatedly, with anyone who would listen, for a long time.
Robison Jewish Health Center is a nonprofit continuing care retirement community in Portland. The facility did not have an opportunity to respond before this article was published.
Resident 87, by the time inspectors arrived, had been itching for months, had told multiple staff members, had apparently told upper management, and had still not had a physician evaluate whether the bedding, or anything else, was causing the problem. The lotion, applied by nurses who saw the scratching and moved on, was the only intervention anyone tried.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Robison Jewish Health Center from 2025-09-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 14, 2026 · Our methodology
ROBISON JEWISH HEALTH CENTER in PORTLAND, OR was cited for violations during a health inspection on September 22, 2025.
The resident's complaints had been going on for months.
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.