Robison Jewish Health Center: Wound Care Failure - OR
That finding, documented during a November 4, 2025 complaint inspection, resulted in a citation for actual harm under the federal standard requiring facilities to identify, assess, and treat pressure ulcers.
The wound was a Stage 2 pressure ulcer located on the left lateral meatus of the penis. Staff 18, a direct care worker, told inspectors she had noticed what appeared to be a sore or cut on the resident's penis and reported it to the nurse on duty. She could not recall which nurse that was. She said she also mentioned the injury to several other nurses, reasoning that any staff member performing catheter or perineal care would see it if they looked closely.
Her description of the wound was specific. She called it a rip. She said it looked like a split, like a hot dog bun. She said discharge was visible every time the brief was changed. She said cleaning the area caused the resident pain.
Nobody wrote it down. Nobody assessed it. Nobody made a care plan.
Staff 4, a Resident Care Manager, told inspectors he had his own encounter with the wound. During an initial visit with the resident, the resident told him something felt like it was pulling in the penis area. Staff 4 said he interpreted that complaint as describing something that had happened in the past, not something the resident was experiencing at that moment. On September 4, 2025, Staff 4 looked at the resident's penis and saw a split roughly an inch long. He reported it to the facility provider.
That was two months before inspectors arrived. There is no indication in the inspection record that an assessment was completed, that the wound was staged, or that a care plan was ever developed following that September report.
At 2:55 in the afternoon on November 4, Staff 2, the Director of Nursing Services, and Staff 3, another Resident Care Manager, told inspectors they had no knowledge of Resident 1's Stage 2 pressure ulcer. Not the wound. Not the report from Staff 18. Not the September observation by Staff 4.
Fifteen minutes later, the Administrator and the Regional Director of Quality Assurance were informed of what inspectors had found: a resident admitted to the facility with a pressure ulcer on the left lateral meatus of the penis that was never identified on admission, never formally assessed, and never entered into a care plan.
The inspection was triggered by a complaint. The citation carries a harm level of actual harm, meaning inspectors determined the failure caused real injury to a real person, not a theoretical risk.
What the record leaves open is how long the resident experienced pain during cleaning before anyone with authority to act treated the wound as a clinical problem requiring a clinical response. Staff 18 reported it. Staff 4 saw it in September. The Director of Nursing found out in November, from inspectors.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Robison Jewish Health Center from 2025-11-04 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 5, 2026 · Our methodology
ROBISON JEWISH HEALTH CENTER in PORTLAND, OR was cited for violations during a health inspection on November 4, 2025.
The wound was a Stage 2 pressure ulcer located on the left lateral meatus of the penis.
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.