Cedar Crossings: Unsecured Medication Carts Found - OR
That was one morning at Cedar Crossings, a nursing facility at 6003 SE 136th Avenue in Portland. Inspectors found the same basic problem four separate times across three days in May, on every medication cart they checked.
The first observation came on May 20, just before noon. Inspectors watched a medication cart on one of the facility's halls for five minutes. It was unlocked. Nobody was with it. A certified medication aide acknowledged it when inspectors pointed it out, confirming the cart was unattended and contained resident medications. The Director of Nursing Services said two days later that the expectation was for carts to be locked whenever staff stepped away.
The next day, May 21, inspectors watched a different cart for about a minute starting at 1:01 in the afternoon. Unlocked. Unattended. An LPN acknowledged it on the spot.
Then came the morning of May 22. At 8:35, inspectors found the cart with the key in the narcotic drawer and a medication cup full of pills on top. An RN was there within a minute and acknowledged all of it: the key, the pills, the unattended cart. Less than 75 minutes later, at 9:49 that same morning, the same RN left a cart unlocked while stepping into a resident's room. She came back and acknowledged that one too.
Four observations. Four unlocked carts. Every hall checked, every time, the same result.
The Director of Nursing Services gave the same answer each time inspectors asked: the expectation was for carts to be locked when unattended. She said it after the first incident. She said it after the second. She said it again after the third and fourth, all on the same morning. The expectation, apparently, was not translating into practice on any hall in the building.
Unsecured medication carts create two distinct risks. Residents, particularly those with dementia or confusion, can access medications not prescribed to them. An unlocked narcotic drawer, with the key left in it, is an open invitation for diversion by anyone passing through a hallway.
Inspectors also found a separate problem in the medication room refrigerator on May 21. A vial of tuberculin, the biological used in tuberculosis testing, was sitting open with no date marked on it. The manufacturer's instructions require the vial to be discarded 30 days after opening. Without an open date, nobody at the facility could know whether that window had passed. An LPN acknowledged the vial was open and undated. The Director of Nursing Services said later that the expectation was for tuberculin to be labeled with an open date when opened.
An expired or degraded tuberculin vial produces unreliable test results. A false negative on a TB test in a congregate care setting, where residents share air and staff move between rooms all day, carries consequences that extend well beyond the single vial.
CMS rated the medication storage violations as causing minimal harm or potential for actual harm, and noted that some residents were affected. The tuberculin labeling issue drew the same designation.
What the inspection record does not show is how long the carts had been left this way before inspectors arrived, or how many times a resident or visitor walked past an unlocked narcotic drawer on a morning when no one happened to be watching.
The Director of Nursing Services knew the expectation. She said so four times.
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.
That was one morning at Cedar Crossings, a nursing facility at 6003 SE 136th Avenue in Portland.
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.