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Complaint Investigation

The Creston Health & Rehabilitation

February 27, 2026 · Portland, OR · 3320 Se Holgate Blvd
Citations 10
CMS Rating 1/5
Beds 100
Provider ID 385121
Healthcare Facility
The Creston Health & Rehabilitation
Portland, OR  ·  View full profile →
Inspection Summary

THE CRESTON HEALTH & REHABILITATION in PORTLAND, OR — inspection on February 27, 2026.

Found 10 citations. Severity: Standard violations.

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

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Inspection Findings

FF0558
Resident Rights Deficiencies
Potential for More Than Minimal Harm

Federal health inspectors cited FRIENDSHIP HEALTH CENTER in PORTLAND, OR for a deficiency under regulatory tag F-F0558 during a standard health inspection conducted on 2026-02-27.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Reasonably accommodate the needs and preferences of each resident.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 10 deficiencies cited during this inspection of FRIENDSHIP HEALTH CENTER.

Correction Status: Deficient, Provider has plan of correction.

The facility reported correction as of 2026-03-31.

Federal health inspectors cited FRIENDSHIP HEALTH CENTER in PORTLAND, OR for a deficiency under regulatory tag F-F0582 during a standard health inspection conducted on 2026-02-27.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 10 deficiencies cited during this inspection of FRIENDSHIP HEALTH CENTER.

Correction Status: Deficient, Provider has plan of correction.

The facility reported correction as of 2026-03-31.

Federal health inspectors cited FRIENDSHIP HEALTH CENTER in PORTLAND, OR for a deficiency under regulatory tag F-F0640 during a standard health inspection conducted on 2026-02-27.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 10 deficiencies cited during this inspection of FRIENDSHIP HEALTH CENTER.

Correction Status: Deficient, Provider has plan of correction.

The facility reported correction as of 2026-03-31.

Federal health inspectors cited FRIENDSHIP HEALTH CENTER in PORTLAND, OR for a deficiency under regulatory tag F-F0677 during a standard health inspection conducted on 2026-02-27.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide care and assistance to perform activities of daily living for any resident who is unable.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 10 deficiencies cited during this inspection of FRIENDSHIP HEALTH CENTER.

Correction Status: Deficient, Provider has plan of correction.

The facility reported correction as of 2026-03-31.

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Federal health inspectors cited FRIENDSHIP HEALTH CENTER in PORTLAND, OR for a deficiency under regulatory tag F-F0679 during a standard health inspection conducted on 2026-02-27.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide activities to meet all resident's needs.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 10 deficiencies cited during this inspection of FRIENDSHIP HEALTH CENTER.

Correction Status: Deficient, Provider has plan of correction.

The facility reported correction as of 2026-03-31.

Federal health inspectors cited FRIENDSHIP HEALTH CENTER in PORTLAND, OR for a deficiency under regulatory tag F-F0685 during a standard health inspection conducted on 2026-02-27.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Assist a resident in gaining access to vision and hearing services.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 10 deficiencies cited during this inspection of FRIENDSHIP HEALTH CENTER.

Correction Status: Deficient, Provider has plan of correction.

The facility reported correction as of 2026-03-31.

falling.

The 1/7/26 Significant Change MDS indicated Resident 2 was unable to complete the BIMS interview and was dependent on staff for mobility, transfers and was unable to ambulate.

The 1/7/26 Fall Risk Assessment indicated Resident 2 was a moderate fall risk.

The 5/30/24 Fall Care Plan indicated Resident 2 had a goal to be free from avoidable falls. A revision to the Fall Care Plan on 1/7/26 directed staff to ensure Resident 2's bed was kept in the lowest position outside of cares.

Observations on 2/24/26 at 11:45 AM and again at 2:34 PM revealed Resident 2 was lying in bed and the bed was not in the lowest position. Resident 2's bed was between knee and waist height (approximately 2-3 feet).

On 2/25/26 at 1:24 PM and 2/26/26 at 5:51 AM, Resident 2 was observed lying flat in bed asleep and the bed was not in the lowest position. Resident 2's bed was at waist level (approximately 3 feet).

On 2/25/26 at 1:19 PM, Staff 22 (CNA) stated Resident 2 was not a fall risk.

Staff 22 was unaware of any fall precautions for Resident 2.

On 2/26/26 at 9:48 AM Staff 25 (LPN) stated Resident 2 was not a fall risk.

Staff 22 was unaware of any fall precautions for Resident 2.

On 2/27/26 at 10:31 AM, Staff 24 (MDS coordinator-RN), Staff 2 (DNS), and Staff 1 (Administrator) confirmed Resident 2's was a moderate fall risk and her/his care plan included intervention for her/his bed to be in the lowest position outside of cares.

Staff 2 and Staff 1 both confirmed they would expect Resident 2's care plan to be followed and her/his bed to be in the lowest position.

Staff 1 confirmed the lowest position would be at approximately 18 inches.

Federal health inspectors cited FRIENDSHIP HEALTH CENTER in PORTLAND, OR for a deficiency under regulatory tag F-F0730 during a standard health inspection conducted on 2026-02-27.

Category: Nursing and Physician Services Deficiencies

The facility was found deficient in the following area: Observe each nurse aide's job performance and give regular training.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 10 deficiencies cited during this inspection of FRIENDSHIP HEALTH CENTER.

Correction Status: Deficient, Provider has plan of correction.

The facility reported correction as of 2026-03-31.

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Federal health inspectors cited FRIENDSHIP HEALTH CENTER in PORTLAND, OR for a deficiency under regulatory tag F-F0732 during a standard health inspection conducted on 2026-02-27.

Category: Nursing and Physician Services Deficiencies

The facility was found deficient in the following area: Post nurse staffing information every day.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 10 deficiencies cited during this inspection of FRIENDSHIP HEALTH CENTER.

Correction Status: Deficient, Provider has plan of correction.

The facility reported correction as of 2026-03-31.

Federal health inspectors cited FRIENDSHIP HEALTH CENTER in PORTLAND, OR for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2026-02-27.

Category: Pharmacy Service Deficiencies

The facility was found deficient in the following area: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 10 deficiencies cited during this inspection of FRIENDSHIP HEALTH CENTER.

Correction Status: Deficient, Provider has plan of correction.

The facility reported correction as of 2026-03-31.

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 THE CRESTON HEALTH & REHABILITATION or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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