She confirmed the odor was terrible.
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The device at the center of the finding was a 2017 Evencare G2 glucometer, used to draw and test blood samples from residents.
The deficiency affected a small number of residents.
A cognitive assessment completed in January 2025 found Resident 132's thinking and decision-making skills intact.
She was wrong, and the care plan said so in plain terms.
The QAPI program is, in theory, the mechanism that prevents exactly this kind of recurrence.
In January 2025, the balance climbed as high as $149,270.15.
That gap, inspectors found, left Resident 3 at risk of being medicated twice.
That gap sits at the center of what inspectors documented during the March 27 survey.
The resident, identified in inspection records as Resident #27, was not wearing her safety alarm device that day.
Resident 40 was admitted to Cedar Crossings, located at 6003 SE 136th Avenue in Portland, in early April 2026.
The staff member present called it dust.