Cedar Crossings: Pharmacist Warnings Ignored Twice - OR
The warning involved a resident admitted in March 2026 with chronic obstructive pulmonary disease and depression. Identified in inspection records as Resident 1, she was receiving Abilify, an antipsychotic prescribed for her depression. On April 17, a consulting pharmacist flagged a problem: nobody had ever completed an AIMS assessment, a standardized test used to screen for involuntary muscle movements that can develop as a serious side effect of antipsychotic medications. The pharmacist asked that the test be done when the drug was started, again at dosage changes, and every six months after that.
The facility did not act.
On May 9, the pharmacist sent the same recommendation again. This time, someone wrote "AIMS Completed" by hand on the document. There was no date. There was no signature. And when inspectors reviewed Resident 1's medical record on May 21, they found no documentation that the assessment had ever actually been done.
The Director of Nursing, identified in the report as Staff 2, acknowledged the failure plainly. She told inspectors that the facility generally tried to address pharmacist recommendations within 72 hours. The AIMS recommendation, she said, "must have fallen through the cracks on both 4/17/26 and 5/9/26." She confirmed the assessment was never completed.
That handwritten note on the May 9 recommendation, claiming a test had been finished, had no author and no timestamp. The record behind it was empty.
A second resident had a different problem, slower to surface but just as straightforward to prevent. Resident 10, admitted in March 2025 with Type 1 diabetes, was taking Venlafaxine, an antidepressant, at 75 milligrams. On April 17, the same pharmacist noticed the medication order was contradictory: the chart listed the drug as both once daily and twice daily. The pharmacist asked the facility to clarify which was correct.
The question sat unanswered for 32 days.
During that entire stretch, Resident 10 was receiving Venlafaxine once a day. Whether that was the right dose, nobody at the facility had confirmed. The pharmacist's communication went unaddressed until May 19, when the Director of Nursing told inspectors she happened to notice the old recommendation while pulling pharmacy records for that resident. She addressed it that day. A progress note from 1:50 PM on May 19 recorded that the medication was changed to once daily per physician order.
The Director of Nursing said the facility typically aimed to close out pharmacist recommendations within 72 hours. For Resident 10, the gap was more than four times that, measured in weeks.
The inspection, conducted May 22, 2026, cited Cedar Crossings for failing to ensure pharmacist recommendations were addressed for two of five residents reviewed. Inspectors assessed the level of harm as minimal harm or potential for actual harm, a designation that reflects risk rather than confirmed injury. The citation covered unnecessary or ineffective medication use.
What the record shows is a system that acknowledged pharmacist guidance as a priority and then, in both cases, failed to follow it. One recommendation was missed once and then missed again. The other sat in a file for over a month until a coincidence surfaced it. And on the document that claimed the safety test had finally been done, nobody left their name.
For Resident 1, the AIMS assessment still had not been completed as of the day 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 warning involved a resident admitted in March 2026 with chronic obstructive pulmonary disease and depression.
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.