Cedar Crossings: Broken Closet Ignored Six Weeks - OR
The resident living with that broken closet, identified in inspection records as Resident 44, moved into the facility in March 2025. The diagnoses on file included schizophrenia. By the time a federal inspector walked into the room on May 18, 2026, at 2:20 in the afternoon, the bottom drawer of the closet had separated from its frame entirely. It sat unsecured on the floor of the closet, no longer attached to anything.
Maintenance records covering March 2026 through May 2026 showed no repair request had ever been submitted for the room.
Three days after that observation, on the morning of May 21, a CNA identified in the report as Staff 14 told the inspector she already knew about the broken drawer. Had known for approximately six weeks, she said.
She had not filed a maintenance request.
The Maintenance Director, Staff 15, said that morning that nursing staff were expected to submit an electronic request whenever they found damaged furniture in a resident's room. He said he had no idea anything was wrong with Resident 44's closet. When he was told what the inspector had found, he acknowledged the drawer was broken and said it needed to come out.
The administrator confirmed it the following day. The closet was in disrepair, Staff 1 said. It had not been reported to maintenance. It had not been repaired in a timely manner.
That is the complete chain of events as documented: a broken piece of furniture, a staff member who saw it and said nothing for a month and a half, a maintenance system that only works when someone uses it, and a room that stayed that way until an outside inspector showed up with a clipboard.
Cedar Crossings is a residential care facility in southeast Portland, at 6003 SE 136th Avenue, serving residents who rely on the facility for daily living supports. The inspection was conducted on May 22, 2026. The deficiency was cited under the standard requiring facilities to maintain a homelike environment, with the level of harm recorded as minimal or potential for actual harm. One of three residents reviewed for environment was affected.
The word "minimal" appears in the official record. It is a regulatory classification. What it describes, in practice, is a person living with schizophrenia who spent at least six weeks with a broken drawer sitting loose on the floor of their closet while the staff member responsible for their care decided not to mention it to anyone.
There is no indication in the inspection report that Resident 44 was injured. There is also no indication that anyone at the facility noticed the problem on their own, or that any internal system caught it, or that a repair would have happened without the inspection. The maintenance logs showed nothing. The electronic request system showed nothing. The only reason anything was acknowledged at all was that someone from outside the building walked in and looked at the closet.
The administrator's confirmation came on the last day of the inspection. By then, the drawer had been broken for roughly six weeks. Whether it was removed or repaired after that conversation, the inspection report does not say.
Resident 44 had been living there for more than a year by the time inspectors arrived.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cedar Crossings from 2026-05-22 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.
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Last verified: October 31, 2026 · Our methodology
CEDAR CROSSINGS in PORTLAND, OR was cited for violations during a health inspection on May 22, 2026.
The resident living with that broken closet, identified in inspection records as Resident 44, moved into the facility in March 2025.
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.