Cedar Crossings: Narcotic Tracking Failures - Portland, OR
When an inspector reviewed the controlled substance book on the facility's named hall on the morning of May 20, 2026, the numbers were off. Page five of the book showed three Norco tablets remaining. The medication card said two. One pill, unaccounted for on paper.
The licensed practical nurse who had worked the night before, identified in the inspection report as Staff 5, told the inspector that evening what had happened. He had worked the night of May 19 and given Norco to a resident. He did not record the administration in the controlled substance book.
That missing entry was not the only problem inspectors found.
The same morning, Staff 5 also told inspectors he had left the facility at the end of his shift without counting the controlled medications with another staff member. That count, done between shifts with two nurses present, is what keeps narcotic inventories accurate and creates a paper trail that can detect diversion. Staff 5 said he simply didn't do it.
The nurse coming on for the day shift, Staff 6, told inspectors the same thing about herself: she had not counted the controlled medications with another staff member before starting her shift. When inspectors reviewed the controlled substance book with her that morning, there were no signatures on the page for the day shift count. Nobody had signed because nobody had counted.
The director of nursing services, identified as Staff 2, told inspectors on May 21 that the expectation was clear. Two staff members were supposed to count controlled medications between every shift, compare what they found to the controlled substance book, and sign the signature page after the count was completed. Each responsible staff member was expected to ensure the numbers matched before they left or arrived.
That expectation had not been met on at least two consecutive shift transitions.
The inspection report covers one of four medication carts reviewed. Inspectors determined the facility failed to ensure narcotic drug records were in order and that a full account of all controlled drugs was maintained for that cart. The cited level of harm was minimal harm or potential for actual harm, and the finding affected a small number of residents.
The gap between what the controlled substance book showed and what was physically in the cart is the kind of discrepancy that narcotic counting procedures are designed to catch quickly. When nurses skip the count, a missing pill can go unnoticed until the next person who bothers to check. In this case, it took an outside inspector sitting down with Staff 6 and the book to surface the one-pill difference.
Staff 5's explanation resolved the math. He gave the pill, he just didn't write it down. But the only reason that explanation was ever sought was because an inspector was in the building.
Cedar Crossings is located at 6003 SE 136th Avenue in Portland. The inspection was completed May 22, 2026.
The resident who received the unrecorded Norco on the night of May 19 had no way of knowing their medication would go undocumented. Their nurse finished the shift, skipped the count, and left.
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.
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.
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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.
When an inspector reviewed the controlled substance book on the facility's named hall on the morning of May 20, 2026, the numbers were off.
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.