The Creston Health & Rehabilitation
3320 Se Holgate Blvd, Portland, OR 97202 · Multnomah County · (503) 231-1411
100 certified beds, about 56 residents a day · Non profit - Corporation · Medicare and Medicaid since 1973
Certified for Medicaid Certified for Medicare
Overall
1 of 5
Health inspections
1 of 5
Staffing
1 of 5
Quality measures
2 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 385121 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on February 27, 2026, inspectors cited 10 health deficiencies (the Oregon average is 9.2, the national average 9.2).
Of 62 health citations since June 2023, 4 were rated as actual harm or immediate jeopardy to residents (1 immediate jeopardy).
CMS lists 3 fines totaling $122,699 in the last three years; the largest was $94,744, and the latest is dated January 6, 2026.
Nurses and nurse aides worked 0.93 hours per resident per day, against 5.03 across Oregon and 3.86 nationally. Registered nurses accounted for 0.33 of those hours.
95.4% of nursing staff left within the year CMS measured (Oregon average 47.4%).
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
1206/23
709/23
407/24
2710/24
102/25
1002/26
106/26
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 62 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
3G
0H
0I
Potential for more than minimal harm
36D
19E
3F
Potential for minimal harm
0A
0B
0C
June 18, 2026Complaint inspection · 1 citation
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure physician orders were implemented in a timely manner for 2 of 3 sampled residents (#s 5 and 6), reviewed for medications. This placed residents at risk for a delay in treatment and recovery.
February 27, 2026Standard inspection, Complaint inspection · 10 citations
- G Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to follow care plan interventions to ensure safe transfers and prevent falls for 3 of 4 sampled residents (#'s 2, 48 and 74) reviewed for accidents. This failure resulted in resident 74 having a fall and sustaining an ankle fracture requiring emergency medical services.
- E Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure overbed lights were accessible, call lights were within reach and bed preferences were honored for 5 of 6 sampled residents (#s 21, 40, 48, 49 and 53) reviewed for accommodation of needs. This placed residents at risk for lack of independence.
- E Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on interview and record review it was determined the facility failed to transmit resident assessments in the required timeframe for 7 of 8 sampled residents (#s 15, 78, 79, 80, 82, 83 and 84) reviewed for late assessments. This placed at risk for untimely assessments, delayed and inaccurate care.
- E Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 5 of 5 sampled CNA staff (#s 5, 10, 11, 12, and 13) reviewed for sufficient and competent nurse staffing. This placed residents at risk for a lack of competent staff.
- E Post nurse staffing information every day.
Inspectors wroteBased on interview and record review it was determined the facility failed to post accurate and complete staffing information for 1 of 1 facility reviewed for required staff postings. This placed residents and the public at risk for incomplete and inaccurate staffing information.
- E 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.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure medications were properly secured, stored, labeled and expired medications were removed from the cart for 3 of 6 sampled medications carts reviewed for medication storage. This placed residents at risk for misappropriation and reduced medication efficacy.
- D Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide SNF ABN (Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage) notifications to 1 of 3 sampled residents (#60) reviewed for Beneficiary Notification. This placed residents and their representatives at risk for unknown financial liabilities.
- D Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure dependent residents received dressing assistance for 1 of 4 residents (#48) reviewed for ADLs. This placed residents at risk for unmet care needs and loss of dignity.
- D Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide an ongoing person-centered activities program for 1 of 3 sampled residents (#48) reviewed for activities. This placed residents at risk for a decline in psychosocial well-being and diminished quality of life.
- D Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure treatment and services to maintain hearing abilities were provided for 1 of 1 sampled resident (#1) reviewed for hearing. This placed residents at risk for social isolation and decreased quality of life.
February 28, 2025Complaint inspection · 1 citation
- D Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview and record review, it was determined the facility failed to assess and conduct weekly wound evaluations for pressure ulcer care for 1 of 3 sampled residents (#3) reviewed for pressure ulcers. This placed residents at an increased risk for delayed healing and inadequate treatment.
October 15, 2024Standard inspection, Complaint inspection · 27 citations
- J Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure residents' change of condition was assessed for 2 of 6 sampled residents (#s 38 and 89) reviewed for hospitalization and unnecessary medications. This failure, determined to be an immediate jeopardy situation, resulted in the delayed assessment of Resident 89 when she/he was experiencing a significant change in condition, resulting in delayed treatment. Resident 89 later died at the hospital. This placed all residents at risk for delayed assessments and treatments and constituted substandard quality of care.
- G Provide or get specialized rehabilitative services as required for a resident.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents received timely specialized rehabilitative services (PT and OT services) for 1 of 1 sampled resident (#20) reviewed for rehabilitation and restorative. This failure resulted in Resident 20 displaying a depressed mood, verbalizing feelings of frustration and a decline in physical functioning.
- F Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were fully informed and understood the binding arbitration agreement for 1 of 1 facility reviewed for binding arbitration agreements. This placed residents at risk of being uninformed regarding their legal rights.
- F Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure community use CBG monitors were cleaned with an approved disinfectant for 3 of 6 sampled units (2, 2D and 1B) observed during medication administration and random observations, failed to implement EBP (enhanced barrier precautions: gloves and gowns worn during high contact for wounds and indwelling devices) timely for 1 of 2 sampled residents (#5) reviewed for pressure ulcers, failed to transport linens in a sanitary manner, and failed to ensure a legionella water management plan for 1 of 1 facility. This placed residents at risk for cross contamination.
- E Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure dignified language was used to address residents and their equipment for 1 of 1 facility and 1 of 2 sampled residents (#14) reviewed for dignity. This placed residents at risk for a decreased quality of life.
- E Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide a homelike environment for 1 of 1 resident (#340) reviewed for hospice and in 1 of 1 facility reviewed for environment. This placed residents at risk for a lack of autonomy and living in an unkempt environment.
- E Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a bed hold policy was provided to a resident when transferred to the hospital for 2 of 2 sampled residents (#s 16 and 33) reviewed for hospitalization. This placed residents at risk for lack of knowledge related to the right to return to the facility.
- E Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure care plans were revised to accurately reflect the needs of residents for 4 of 13 sampled residents (#s 5, 7, 35, and 73) reviewed for accidents, pressure ulcers, position and mobility. This placed residents at risk for unmet needs.
- E Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, interview and record review, it was determined the facility failed to provide an ongoing program to support individual activity interests and preferences for 4 of 4 sampled residents (#s 38, 51, 53 and 340) reviewed for activities. This placed residents at risk for isolation, lack of social interaction and engagement.
- E Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure a resident was provided restorative services and a resident with limited range of motion received appropriate treatment and services to prevent further decreases in range of motion for 4 of 10 sampled residents (#s 5, 7, 16 and 50) reviewed for ADLs and mobility. This placed residents at risk for decrease in range of motion and worsening contractures.
- E Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview and record review it was it was determined the facility failed to ensure a medication error rate of less than 5%. The facility administration error rate was 19.23% with 5 errors in 26 opportunities. This placed residents at risk for an ineffective medication regimen.
- E 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.
Inspectors wroteBased on observation and interview it was determined the facility failed to ensure medications and biologicals were secured and accessible only to authorized personnel for 5 of 6 halls (1B, 1C, 1D, 2C and 2D) observed for secure medication and treatment carts. This placed residents at risk for misappropriation of medications and adverse medication consequences.
- E Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure foods were labeled and stored to ensure proper food storage practices were followed in 1 of 1 kitchen reviewed. This placed residents at risk for foodborne illness.
- D Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on interview and record review it was determined the facility failed to obtain consents for the use of psychotropic medications for 2 of 6 sampled residents (#s 1 and 77) reviewed for medications. This placed residents at risk for the loss of the right to decline the use of psychotropic medications.
- D Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to honor a resident's preference for room layout for 1 of 2 sampled residents (#16) reviewed for choices. This placed residents at risk for depression.
- D Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents had an advance directive for 2 of 4 sampled residents (#s 1 and 16) reviewed for advance directives. This placed residents at risk for end-of-life choices not being honored.
- D Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident's emergency contact was notified of a resident's hospitalization for 1 of 2 sampled residents (#16) reviewed for hospitalization. This placed residents' representatives at risk for not being informed of a resident's change in medical condition.
- D Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure NOMNC (Notice of Medicare Non-Coverage) notifications were provided to 2 of 3 sampled residents (#s 75 and 290) and failed to provide SNF ABN (Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage) notifications to 2 of 3 sampled residents (#s 49 and 75) reviewed for Beneficiary Notification. This placed residents and their representatives at risk for lack of knowledge regarding their right to appeal and unknown financial liabilities.
- D Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a system was in place to resolve resident grievances promptly for 1 of 1 resident (#57) reviewed for abuse. This placed residents at risk for unresolved grievances.
- D Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to accurately assess residents for communication, dental, and transfers for 3 of 9 sampled residents (#s 1, 14 and 20) reviewed for communication, dental, and rehabilitation. This placed residents at risk for inaccurate assessments and unmet care needs.
- D Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide appropriate treatment and services in the area of communication for 1 of 4 sampled residents (#53) reviewed for communication. This placed residents at risk for diminished quality of life and potential decline in their ability to carry out activities of daily living.
- D Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide the necessary care and services to maintain personal hygiene for 1 of 5 sampled residents (#51) reviewed for ADLs. This placed residents at risk for poor personal hygiene.
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were free from accident hazards for 3 of 6 sampled residents (#s 6, 50 and 60) reviewed for accidents. This placed residents at risk for falls and adverse medication consequences.
- D Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide treatment and services to correct ongoing signs of depressive behavior for 1 of 1 sampled resident (#20) reviewed for behaviors. This placed residents at risk for not maintaining their highest practicable physical, mental and psychosocial well-being.
- D Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to obtain and provide routine medication for 2 of 5 sampled residents (#s 33 and 49) reviewed for unnecessary medications. This placed residents at risk for not receiving prescribed medications.
- D Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident was monitored for side effects of antidepressants for 1 of 5 sampled residents (#1) reviewed for unnecessary medications. This placed residents at risk for an adverse medication regimen.
- D Provide or obtain dental services for each resident.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure a follow-up dental exam was scheduled for 1 of 4 sampled residents (#16) reviewed for dental. This placed residents at risk for delayed treatment.
July 30, 2024Complaint inspection · 4 citations
- G Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Inspectors wroteBased on interview and record review, the facility failed to complete a discharge summary with required information for wound care and possible wound infection for 1 of 1 sampled resident (# 17) reviewed for unsafe discharge. The facility's failure to provide instructions for the care of the wound and the possible wound infection in the discharge summary information caused the resident's wound to worsen at home resulting in re-admission to a hospital.
- D Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician orders and provide correct oxygen administration for 1 of 3 sampled residents (#12) reviewed for physician orders. This placed residents at risk for improper oxygen administration.
- D Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure licensed nursing staff possessed the competencies and skill sets necessary related to oxygen administration for 1 of 3 sampled residents (#12) reviewed for physician orders. This placed all residents at risk for unsafe oxygen administration.
- D Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure wheelchairs were clean and sanitary for 1 of 3 sampled residents (#13) reviewed for equipment. This placed residents at risk for unclean wheelchairs.
September 18, 2023Complaint inspection · 7 citations
- F Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on interview and record review the facility failed to implement a Quality Assessment and Performance Improvement (QAPI) program which identified quality deficiencies, developed and implemented action plans to correct identified quality of care deficiencies. The facility failed to initiate a QA review related to staffing despite multiple concerns relayed to management by staff and residents and failed to respond to complaints and grievances filed by residents related to staffing shortages for 8/2023. This placed all residents at risk of not receiving the care and services for optimal resident outcomes.
- E Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents were free from neglect. The facility failed to ensure residents received basic care for 4 of 4 sampled residents (#s 200, 300, 500, and 700) reviewed for ADL's. This neglect was due to the failure of the facility to provide adequate staffing which resulted in long call light times, lack of timely incontinence care and showers not completed on scheduled days. This failure placed all residents at risk for neglect of care.
- E Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were free from misappropriation of personal property for 2 of 2 sampled residents (#s 400 and 800) reviewed for misappropriation of property. This placed residents at risk for theft. Findlings include: 1. Resident 800 was admitted to the facility on [DATE] with diagnoses including amputation of the left leg below the knee and anxiety disorder. Resident 800's Quarterly MDS dated [DATE] revealed she/he was cognitively intact with a BIMS score of 15. On 8/28/23 the facility reported to the State Agency Resident 800 reported her/his credit/debit card had been stolen 7/2023. The resident initially thought the card was accidentally thrown away but subsequently learned charges were made to the card that she/he had not authorized. [...]
- E Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide ADL care to 4 of 4 sampled residents (#s 200, 300, 500 and 700) reviewed for ADLs. This placed residents at risk for unmet needs.
- E Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs for 1 of 1 facility reviewed for sufficient and competent staffing. This placed residents at risk for delayed and unmet care needs.
- D Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure Staff 9 (Agency CNA) met professional standards of care for 1 of 3 sampled residents (#500) reviewed for incidents. This placed residents at risk for unmet care needs.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician's orders for 1 of 3 sampled residents (#200) reviewed for physician orders. This placed residents at risk for lack of medical care.
June 30, 2023Standard inspection · 12 citations
- E Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation and interview it was determined the facility failed to maintain comfortable sound levels for 1 of 1 facility observed for environment. This placed residents at risk for an uncomfortable environment.
- D Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents were assessed for self-administration of medications and a physician order was in place for 1 of 6 sampled residents (#6) observed for medication administration. This placed residents at risk for adverse medication-related consequences.
- D Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure a call light was readily accessible for 1 of 1 resident (#1) reviewed for accommodation of needs. This placed the resident at risk for delayed staff assistance.
- D Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure MDS assessments were coded accurately for 3 of 7 sampled residents (#s 2, 18 and 35) reviewed for food and unnecessary medications. This placed residents at risk for inaccurate assessments.
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to implement the care plan related to positioning in bed for meals for 1 of 4 sampled residents (#1) reviewed for ADLs. This placed residents at risk for loss of independence, safety and comfort with eating.
- D Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide ADL care to dependent residents for 2 of 4 sampled residents (#s 8 and 19) reviewed for ADL care. This placed residents at risk for unmet hygiene needs.
- D Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide support for a resident's choice of independent activities for 1 of 2 sampled residents (#34) reviewed for activities. This placed residents at risk for unmet psychosocial needs and isolation.
- D Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview and record review it was determined the facility failed to consistently perform pressure ulcer assessments and wound care for 1 of 4 sampled residents (# 56) reviewed for pressure ulcer care. This placed residents at risk for worsening pressure ulcers.
- D Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to follow physician orders for oxygen therapy for 1 of 1 sampled resident (#25) reviewed for oxygen. This placed residents at risk for unnecessary oxygen therapy.
- D Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure physician visits occurred as required for 1 of 5 sampled residents (#40) reviewed for unnecessary medications. This placed residents at risk for unassessed needs.
- D Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure a medication pass error rate of less than 5%. There were three errors in 28 opportunities resulting in a 10.71% error rate. This placed residents at risk for reduced medication efficacy and adverse medication side effects.
- D Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure resident records were accurate for 2 of 10 sampled residents (#s 6 and 56) reviewed for medication administration and pressure ulcer care. This placed residents at risk for inaccurate health records and worsening pressure ulcers.
Fire safety inspections
18 fire safety citations on file: 3 on February 27, 2026, 1 on October 30, 2024, 6 on October 15, 2024, 8 on June 30, 2023.
Every fire safety citation18 citations
- F Develop Emergency Preparedness policies and procedures.
- F Establish policies and procedures for volunteers.
- F Inspect, test, and maintain automatic sprinkler systems.
- F Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- F Have approved installation, maintenance and testing program for fire alarm systems.
- F Inspect, test, and maintain automatic sprinkler systems.
- F Have simulated fire drills held at unexpected times.
- F Have generator or other power source capable of supplying service within 10 seconds.
- E Properly select, install, inspect, or maintain portable fire extinguishes.
- D Ensure proper usage of power strips and extension cords.
- F Have approved installation, maintenance and testing program for fire alarm systems.
- F Inspect, test, and maintain automatic sprinkler systems.
- F Properly select, install, inspect, or maintain portable fire extinguishes.
- F Have generator or other power source capable of supplying service within 10 seconds.
- E Keep aisles, corridors, and exits free of obstruction in case of emergency.
- E Have stairways and smokeproof enclosures used as exits that meet safety requirements.
- D Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- D Have restrictions on the use of highly flammable decorations.
Fines and payment denials
| Date | Penalty | Amount or length |
|---|---|---|
| January 6, 2026 | Fine | $19,135 |
| October 15, 2024 | Fine | $94,744 |
| July 30, 2024 | Fine | $8,820 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Oregon | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 0.93 | 5.03 | 3.86 |
| Registered nurses | 0.33 | 0.72 | 0.69 |
| All nursing staff on weekends | 0.95 | 4.51 | 3.42 |
| Nurse aides | 0.27 | ||
| Licensed practical nurses | 0.34 | ||
| Nursing staff turnover (share who left in a year) | 95.4% | 47.4% | 45.8% |
| Registered nurse turnover | 91.7% | 51.6% | 42.9% |
| Administrators who left | not reported |
CMS expects 3.83 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 0.92 on weekdays and 0.95 on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 100.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 6.22 in April to June 2025 to 0.93 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 0.93 | 0.33 | 0.92 | 0.95 | 100.0% | 3 of 90 | 56 |
| Oct to Dec 2025 | 5.62 | 1.02 | 5.81 | 5.14 | 18.1% | 0 of 92 | 58 |
| Jul to Sep 2025 | 5.64 | 0.68 | 5.87 | 5.04 | 43.0% | 0 of 92 | 60 |
| Apr to Jun 2025 | 6.22 | 0.55 | 6.44 | 5.65 | 44.2% | 0 of 91 | 66 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Oregon, Jan to Mar 2026 | 4.91 | 0.64 | 5.12 | 4.40 | 6.2% | 0.4% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
Staff pay at this home
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.
Official wage estimates for Oregon
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Oregon, all employers | |||
| CNAs (nursing assistants) | $23.96 | $22.83 to $28.40 | 14,800 |
| LPNs and LVNs | $38.69 | $35.11 to $43.60 | 4,260 |
| Registered nurses | $62.02 | $51.55 to $64.63 | 39,730 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Oregon | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 25.7 | 14.9 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.7 | 1.4 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 2.0 | 2.0 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 2.0 | 2.4 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.7 | 1.4 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 21.0 | 20.6 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 12.5 | 5.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 9.7 | 13.9 | 15.4 |
Owners and operators
Legal business name: Legal Business Name Not Available.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Ownership data not available |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 22 problems in this area, most recently on June 18, 2026: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 14 problems in this area, most recently on February 27, 2026: "Reasonably accommodate the needs and preferences of each resident."
- When is the care plan meeting, and can family attend it?Inspectors cited 8 problems in this area, most recently on February 27, 2026: "Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment."
- How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 6 problems in this area, most recently on February 27, 2026: "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."
- Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 0.95 hours per resident per day, below the Oregon average of 4.51.
Other nursing homes nearby
- Reedwood Post Acute Portland, 0.3 mi · 5 of 5 stars · 11 citations
- Laurelhurst Post Acute & Rehabilitation Portland, 2 mi · 1 of 5 stars · 49 citations
- Mirabella Portland Portland, 2 mi · 5 of 5 stars · 8 citations
- Belmont Care and Rehabilitation Portland, 2.1 mi · 2 of 5 stars · 37 citations
- Mt. Tabor Health & Rehabilitation Portland, 2.3 mi · 2 of 5 stars · 44 citations
- Providence Child Center Portland, 2.9 mi · 5 of 5 stars · 13 citations
- Holladay Park Plaza Portland, 3 mi · 5 of 5 stars · 18 citations
- Secora Rehabilitation of Cascadia Portland, 3.4 mi · 3 of 5 stars · 37 citations
Oregon contacts for a concern about a nursing home
These are the official offices in Oregon. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Oregon Department of Human Services, Nursing Facility Licensing, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Oregon Office of the Long-Term Care Ombudsman, (800) 522-2602. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: Oregon Licensed Long-Term Care Settings Search, where Oregon publishes its own records on licensed homes.
Common questions
- What is The Creston Health & Rehabilitation's Medicare star rating?
- CMS rates The Creston Health & Rehabilitation 1 out of 5 stars overall, with 1 for health inspections, 1 for staffing and 2 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did The Creston Health & Rehabilitation get at its last inspection?
- 10 health deficiencies at the standard inspection on February 27, 2026. The Oregon average is 9.2.
- Has The Creston Health & Rehabilitation been fined?
- Yes. CMS lists 3 fines totaling $122,699 in the last three years.
- Does The Creston Health & Rehabilitation accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns The Creston Health & Rehabilitation?
- CMS lists 1 owner or manager. Legal business name: Legal Business Name Not Available.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.