Traditions Health
A hospice in Portland, Oregon 97232
919 NE 19th Street, Suite 160n, Portland, Oregon 97232. (877) 263-7776.
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The short answer
Record last released by CMS on Oct 23, 2026.
- 11 deficiencies cited in the last three years
- 2of 5 family caregiver rating
- 10of 10 CMS’s Hospice Care Index
Each figure’s source sits beside it, in its section below.
What these words mean4
- Star ratings
- CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
- Condition-level deficiency
- For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual.
What did inspectors find?
11 deficiencies cited in the last three years
The middle of the 19 hospices serving ZIP code 97232 had 4.5.
The last inspection on record was on Jan 5, 2024: a follow-up inspection by The Joint Commission.
2 deficiencies at condition level, the more serious of CMS’s two levels
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
CMS, Hospice ZIP Data. Released Aug 26, 2026. Updated quarterly.
When those deficiencies happened
11 deficiencies in 2 months of the last 36. Last cited Jan 2024. Most serious: Condition-level. The last 3 years, to Oct 27, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Nov | Dec | ||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Jan 5, 2024: follow-up inspection by The Joint Commission1 deficiency
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Content of comprehensive assessment (42 CFR 418.54(c)(7))
“Observed in Record Review. In 2 of 3 patient records reviewed, The surveyor found in 2/3 records reviewed that the organization had not measured wounds weekly as required by HCO policy. The surveyor reviewed 3 records with wounds and 2/3 records reviewed with wounds did not have wound measurements. The dates of issue related to lack of documented wound measures were between 12/15/2023 and 1/5/2024. The surveyor discussed and confirmed the issue with organization leaders.”
Dec 1, 2023: initial inspection by The Joint Commission10 deficiencies
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Initial & comprehensive assessment of patient (42 CFR 418.54)
The inspectors’ words, 112 words
“Observed in Record Review. In 10 of 19 patient records reviewed, the organization did not ensure that comprehensive assessments and reassessments adequately evaluated patients’ needs for care and services. For example, in RRHV#1 an RN did not document the presence of an indwelling foley catheter, nor a feeding tube. And the stoma was not evaluated. In RRNHV#1 an RN documented that a wound on the left side of the patient’s jaw was open through to the mouth cavity. Measurements were not recorded. In RRHV#4, RRNHV#2, RRNHV#3, RRNHV#5, RRNHV#8, RRBR#1, RRBR#2, and RRBR#3 bereavement, psychosocial, and/or spiritual assessments were not documented. This RFI was reviewed with the Administrator, Clinical Specialist, and Branch Director.”
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Governing body and administrator (42 CFR 418.100(b))
“Observed in Tracer Activities. leaders did not manage implementation of patient care policies and procedures governing the provision of care. Documentation failures were identified in the following: required assessments and reassessments; plan of care revisions; patient goals; and provision of bereavement services. This RFI was reviewed with the Branch Director and reviewed with the Administrator and Clinical Specialist.”
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Timeframe for completion of assessment (42 CFR 418.54(b))
“Observed in Proficiency Testing. In 2 of 19 patient records reviewed, the organization did not document completion of the initial comprehensive assessment within five days of election of the hospice benefit. For example, in RRNHV#1, and RRNHV#8 bereavement, psychosocial and/or spiritual assessments were not documented within the specified time frame. This RFI was reviewed with the Administrator, Clinical Specialist, and Branch Director.”
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Update of comprehensive assessment (42 CFR 418.54(d))
The inspectors’ words, 108 words
“Observed in Record Review. In 15 of 19 patient records reviewed, where the interdisciplinary group met two or more times for patients receiving services, the organization did not update comprehensive assessments to reflect changes that occurred since the initial assessment. Interdisciplinary notes did not consistently document patient decline, for example, decreased ambulation, decreased appetite, weight loss, or use or change in use of opioids; progress toward goals; and plans for the next two weeks. These omissions were noted in records RRHV#2, RRHV#3, RRHV#4, RRNHV#1, RRNHV#2, RRNHV#3, RRNHV#4, RRNHV#5, RRNHV#6, RRNHV#7, RRNHV#8, RRNHV#9. RRNHV#10, RRDC#1, and RRBR#3. This RFI was reviewed with the Administrator, Clinical Specialist, and Branch Director.”
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Content of plan of care (42 CFR 418.56(c))
The inspectors’ words, 152 words
“Observed in Record Review. In 19 of 19 patient records reviewed, the organization did not develop plans of care that were based on patient’s goals and the time frames, settings, and services required to meet those goals. In all records reviewed most goals were not specific, measurable, and did not identify targeted dates for completion. For example: Pain will be managed at a level acceptable to the patient; patient/caregiver will have decreased fear/anxiety regarding death and dying process; laboratory results will guide hospice IDT in the provision of providing comfort care and system management; patient/caregiver will express an increased sense of closure and peacefulness at the end of life; caregiver will experience a sense of accomplishment at having supported the dying person; medications will be managed appropriately as evidenced by steady symptom control. And few identified when completion would occur. This RFI was reviewed with the Administrator, Clinical Specialist, and Branch Director.”
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Content of plan of care (42 CFR 418.56(c)(4))
“Observed in Record Review. In 1 of 19 patient records reviewed, the plan of care did not include all medications and treatments necessary to meet the patient’s needs. For example, in record RRHV#3, and RRNHV#2 an RN documented in the initial comprehensive nursing assessments that these patients were using oxygen, however, there were no orders found in the plans of care. This RFI was reviewed with the Administrator, Clinical Specialist, and Branch Director.”
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Coordination of services (42 CFR 418.56(e)(2))
“Observed in Record Review. In 2 of 3 patient records reviewed, the organization did not provide services according to the individualized plan of care. In RRBR#1 bereavement services were provided for just three months. In RRBR#2 no bereavement services were provided. There was no documentation that families requested the service to end. This RFI was reviewed with the Administrator, Clinical Specialist, and Branch Director.”
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Content (42 CFR 418.104(a)(7))
The inspectors’ words, 97 words
“Observed in Record Review. In 1 of 19 patient records reviewed, the patient record did not contain the following clinical information: - A list of medications, including dose, strength, frequency, route, date and time of administration. In record RRHV#1 Morphine Sulfate concentrate 20mg/ml to be given orally was listed. There were additional directions to give the drug via peg tube every hour as needed for pain, which contradicted the oral route of administration. The documentation should have instructed that the drug be given by sublingual route. This RFI was validated by the Clinical Specialist and Branch Director.”
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Authentication (42 CFR 418.104(b))
“Observed in Record Review. In 1 of 19 patient records reviewed, the organization did not ensure that all entries in the patient record were complete, and appropriately authenticated in accordance with organization policy, and currently accepted standards of practice. For example, in record RRHV#3 the Election of Benefits was not signed by a clinician. This RFI was reviewed with the Administrator, Clinical Specialist, and Branch Director.”
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Coordination of services (42 CFR 418.112(e)(3))
The inspectors’ words, 171 words
“Observed in Patient Home. In 1 of 4 home visits conducted, the organization did not provide the SNF with the following information: - The patient’s most recent hospice plan of care - The patient’s hospice election form and any advance directives - The physician certification and recertification of the patient’s terminal illness - The names and contact information of hospice staff involved in the care of the patient - Instructions on how to access the hospice’s 24-hour on-call system - Information on the hospice medications for the patient - Orders from the hospice physician and attending physician, if any, for the patient. During home visit RRHV#1 there was no folder containing the above information in the skilled nursing facility. The Administrator stated that he had never seen a folder for this patient. And at home visit RRHV#2 there also no folder for the surveyor to review in the foster home. The caregiver did not know where it was located. This RFI was reviewed with the Administrator, Clinical Specialist, and Branch Director.”
All 3 inspections in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Jan 5, 2024 | Follow-up inspection by The Joint Commission | 1 deficiency cited |
| Dec 5, 2023 | Complaint inspection by the state | No deficiencies cited |
| Dec 1, 2023 | Initial inspection by The Joint Commission | 10 deficiencies cited |
Is it certified?
- Medicare-certified hospice since Jul 1, 2004.
- Ownership: for-profit.
- Cited at For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. in the last three years: it didn’t meet a whole condition of Medicare’s rules.
CMS, Hospice General Information. Released Aug 26, 2026. Updated quarterly.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Has anything been proven against it?
- CMS doesn’t publish fines or other penalties for hospices, so none are shown.
- 0 deficiencies cited in the last three years came from inspections that included a complaint investigation.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Who does the caring?
- From Medicare claims (Jan 1, 2023 to Dec 31, 2024): 13.9 nurse care minutes per routine home care day, 7% of skilled nursing minutes at weekends and a visit near death for 91.5% of patients who died.
- Where its patients were cared for (Jan 1, 2024 to Dec 31, 2024): 46% at home, 45% in assisted living, 8% in a nursing facility, 1% in a skilled nursing facility.
CMS, Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
| Measure | This provider |
|---|---|
| Nurse care minutes per routine home care day | 13.9 min |
| Skilled nursing minutes at weekends | 7% |
| Visits near death | 91.5% of patients who died |
Who owns it?
- Mission Hospice of Portland Holdings LLC owns 100% directly since Dec 3, 2025.
- 5 owners or officers are people: Angela Dey Collins (corporate officer); Fahad Jamil (managing employee (under contract)); Jose Salvidor Delacruz (managing employee (under contract)); Kimberly Jean Brenay (managing employee (on the payroll), 0%); Elizabeth Ann Zink-Pearson (corporate officer, 0%).
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospice All Owners and Hospice Enrollments. Released Sep 29, 2026. Updated quarterly.
| Organisation | Role | Share | Since |
|---|---|---|---|
| Mission Healthcare Intermediate Holdings LLC | Owns 5% or more through other companies | 100% | Dec 3, 2025 |
| Mission Healthcare Services, LLC | Owns 5% or more through other companies | 100% | Dec 3, 2025 |
| Mission Hospice of Portland Holdings LLC | Owns 5% or more directly | 100% | Dec 3, 2025 |
| Tvg Mh Intermediate Holdings LLC | Owns 5% or more through other companies | 100% | Dec 3, 2025 |
| Tvg MH Holdings LLC | Owns 5% or more through other companies | 100% | Dec 3, 2025 |
| Tvg Bolt Buyer, LLC | Owns 5% or more through other companies | 47.79% | Dec 3, 2025 |
| Vistria Fund III LP | Owns 5% or more through other companies | 32.05% | Dec 3, 2025 |
| MH Holdings Management Holdco LLC | Owns 5% or more through other companies | 21.47% | Dec 3, 2025 |
| Tvg MH Holdings III (Ft) LP | Owns 5% or more through other companies | 15.73% | Dec 3, 2025 |
| Tvg Mh III (Ft) Blocker LLC | Owns 5% or more through other companies | 15.73% | Dec 3, 2025 |
| Vistria Fund III (Ft) LP | Owns 5% or more through other companies | 15.33% | Dec 3, 2025 |
| Capricorn Healthcare & Special Opportunities II, LP | Owns 5% or more through other companies | 9.49% | Dec 3, 2025 |
What do families say?
- Family caregivers rate it 2 of 5 in CMS’s survey (Oct 1, 2023 to Sep 30, 2025): 78% rated it 9 or 10 out of 10, and 77% would definitely recommend it.
- CMS’s Hospice Care Index: 10 of 10 (Jan 1, 2023 to Dec 31, 2024).
- 100% of patients were assessed on all seven of CMS’s measures at the start of care (Oct 1, 2024 to Sep 30, 2025); 44.5% had visits from a nurse or social worker on at least 2 of their last 3 days (Jan 1, 2023 to Dec 31, 2024).
CMS, CAHPS Hospice Survey and Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Family caregiver survey ratingCMS star rating from its survey of patients’ family caregivers, 1 to 5 | 2 of 5 |
| Hospice Care IndexCMS’s Hospice Care Index, 0 to 10 (higher is better): a point for each of ten measures from Medicare claims on which the hospice meets CMS’s threshold | 10 of 10 |
How does it compare nearby?
- Of the 19 hospices CMS’s data show serving patients in ZIP code 97232, where this hospice’s office is, the middle number of deficiencies cited in the last three years was 4.5; this one had 11.
CMS, Hospice ZIP Data. Released Aug 26, 2026. Updated quarterly.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
| Place | Deficiencies, 3 years |
|---|---|
| Kaiser Permanente Continuing Care Services Hospice | Not given |
| Traditions Health This hospice | 11 |
| Providence Hospice | 6 |
| Adventist Health Hospice | 2 |
| CARE Partners | 2 |
| Housecall Providers Hospice | 5 |
| Accentcare Hospice & Palliative Care of Oregon | 19 |
| Forest Park Healthcare at Home | 1 |
| Heart 2 Heart Hospice Care LLC | 6 |
| Legacy Hospice Services | 3 |
| Northwest Hospice, LLC | 0 |
| Serenity Hospice | 8 |
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospices, so none are shown.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- CMS ended its Special Focus Program for hospices with serious problems on Feb 14, 2025, so no hospice is marked as one.
- Hospice quality measures have a gap from October 2025: CMS replaced its patient assessment then, and public results from the new one (HOPE) are expected around November 2027.
Sources
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Centers for Medicare & Medicaid Services, Hospice General Information (yc9t-dgbk).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice Provider Data (252m-zfp9).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, CAHPS Hospice Survey (gxki-hrr8).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR hospice inspection reports (Hospice Survey Reports - Oct 2021 through Sep 2026.xlsx).
Released Oct 23, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice All Owners (e983965e-1603-4cb8-82b5-c40090e380d1).
Released Sep 29, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice Enrollments (25704213-e833-4b8b-9dbc-58dd17149209).
Released Sep 29, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice ZIP Data (95rg-2usp).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Oct 27, 2026.
From the hospice
The public record above comes first. Anything the hospice adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospice will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospice”, and paying will never change a finding, a rating or the order of results.