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Complaint Investigation

Laurelhurst Post Acute & Rehabilitation

Inspection Date: September 8, 2025
Total Violations 1
Facility ID 385010
Location PORTLAND, OR
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Inspection Findings

F-Tag F0627

Resident Rights Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for

a safe transfer/discharge.

Based on interview and record review it was determined the facility failed to ensure a safe discharge for 1 of 3 sampled residents (#1) reviewed for discharges. This placed residents at risk for an unsafe discharge and potential rehospitalization. Findings include:Resident 1 was admitted to the facility on 4/2024, with diagnoses including fibular fracture.Resident 1's 4/15/24 Discharge Care Plan indicated the resident was anticipated to discharge home. Social Services was to arrange support services such as home health (HH) caregiver support, PT, and OT.A 6/12/24 Physician Note revealed the resident would benefit from HH, PT, and OT after discharge.A 6/12/24 Social Services Note revealed a referral was sent to a Home Health agency.A 6/14/24 Social Services Note revealed Resident 1 decided to remain at the facility and had paid for two weeks in advance.Resident 1's 6/19/24 Discharge Summary revealed the resident was discharged from the facility on 6/19/24 without a HH referral.On 9/5/25 at 1:57 PM, Staff 16 stated she did not recall what happened with the Home Health referral for Resident 1.On 9/8/25 at 9:38 AM, Witness 10 (Home Health) stated the agency received a referral for Resident 1 on 6/12/24 with the discharge planned for 6/14/24. The agency called Staff 16 on 6/14/24 as the referral was not complete and was informed that Resident 1 was no longer planning to discharge and to cancel the referral.On 9/8/25 at 12:25 PM, Resident 1 stated Staff 16 knew she/he planned to discharge home on 6/19/24. Resident 1 stated she/he was without caregiver supports until she/he arranged services and supports through her/his physician. Resident 1 stated her/his family member had to quit two jobs in order to provide ADL care until home health caregiver support services were in place. On 9/8/25 at 1:45 PM, Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Resident 1 discharged home without a home health referral for caregiver support, PT, and OT services.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

📋 Inspection Summary

LAURELHURST POST ACUTE & REHABILITATION in PORTLAND, OR inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in PORTLAND, OR, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from LAURELHURST POST ACUTE & REHABILITATION or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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