Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oregon Care Center during CMS and state inspections, most recent first.
Failure to obtain written consent for psychotropic medications for two residents. One resident had anxiety, depression, schizophrenia, and non-Alzheimer’s dementia, and the other had depression, schizophrenia, and traumatic brain injury with communication problems and dependence on staff for care. Records showed psychotropic orders including antipsychotic and antidepressant medications, but no consent forms were on file. An LPN was unsure about consent requirements, and the DON and Administrator stated they had interpreted the policy incorrectly.
A CMT left a medication cart computer screen open, unlocked, and visible while walking away from the cart and entering resident rooms and a shower room, exposing confidential resident information. The issue involved three residents with significant medical and functional needs, including cognitive impairment, blindness, TBI, diabetes, HTN, heart failure, and use of anticoagulant, antiplatelet, antipsychotic, and antidepressant medications. The CMT, an LPN, the DON, and the Administrator all stated the screen should not be left open and visible.
Unsafe and Poorly Maintained Environment: The facility failed to maintain a safe, comfortable, and homelike environment for all residents. Surveyors observed dented baseboard heaters protruding into the hallway, chipped and splintered handrails, missing drywall, and handrails with missing paint and splintering. The Mnt Supv stated he was responsible for repairs to the walls, handrails, and baseboard heaters but had not had time to complete the needed repairs, and the Adm stated she expected the maintenance dept to keep all areas in good repair.
Failure to complete and follow pharmacist medication regimen reviews: The facility did not document timely physician follow-up on pharmacy recommendations for three residents. One resident with dementia and heart failure received Seroquel without a listed diagnosis, another resident with seizure disorder had no documented Keppra level order or results despite a pharmacy note, and a third resident with dementia, anxiety, depression, and schizophrenia remained on venlafaxine without a GDR. The DON said pharmacy recommendations should be reviewed by the physician within 48 hours, and the administrator expected monthly med regimen reviews for all residents.
Kitchen and Dining Room Not Kept in Good Repair: Surveyors observed multiple sanitation and repair issues in the kitchen and dining room, including broken and missing floor tiles, black stains and substances on doors and walls, damaged storage doors, broken blinds, and dining chairs with ripped seats and exposed foam. A resident with no cognitive impairment and supervision needs for ADLs reported the broken chairs were uncomfortable and the broken blinds affected meals; the Maintenance Supervisor and Administrator both stated the areas and furniture should be in good repair.
A resident with dementia, anxiety, depression, and later schizophrenia/schizoaffective disorder had a significant change assessment showing disorganized thinking and difficulty focusing attention, but the facility did not complete a new PASARR reassessment after the new serious mental illness diagnosis appeared. The prior Level I PASARR had found no major mental disorder, and the Administrator stated a new PASARR should have been completed.
Unsecured controlled medication in medication refrigerator: Three bottles of liquid lorazepam were found in the medication fridge without the required double-lock protection. The fridge lock was sitting on a counter, a piece of the locking mechanism was not attached, and staff including CMTs, an LPN, and the Administrator gave inconsistent or limited awareness of how long the lock had been broken.
A resident with severe cognitive impairment and a history of behavioral issues entered another resident's room and kicked them in the shin, causing pain and redness. The incident was not witnessed by staff but was reported by the injured resident and confirmed by assessment. The aggressive resident had a recent history of illness and increased behavioral symptoms, while the injured resident was cognitively intact and at risk for skin issues.
The facility failed to employ a qualified director of food and nutrition services, affecting all 44 residents receiving meals from the facility's kitchen. The Dietary Manager (DM) was not a Certified Dietary Manager (CDM) as required, despite being in the position since July 2023 and having worked at the facility for ten years. The Registered Dietitian (RD), who consulted monthly, confirmed the DM's lack of qualifications and had recommended certification, but the DM had not pursued it. The Administrator also confirmed the DM's lack of required credentials.
An incident occurred in a facility where a resident with severe cognitive impairment and a history of aggression struck another resident in the dining room. The altercation was triggered when the resident felt trapped, leading to a physical confrontation. Staff intervened promptly, and the incident was reported to the state agency. The facility's investigation noted the resident's history of delusional behaviors due to a UTI and the need for careful monitoring.
A facility failed to ensure proper insulin pen usage for a diabetic resident, as a CMT administered insulin without priming the needle set, contrary to manufacturer's instructions. Additionally, physician orders for a resident with a feeding tube lacked specified volume for Isosource formula, despite repeated requests for clarification by a dietitian.
The facility failed to secure medications and ensure proper administration, as medications were left unattended in front of two residents without self-administration orders. Additionally, an unlocked medication cart was left unattended in the lobby. The Assistant Director of Nursing and the Administrator acknowledged these lapses, which contributed to a deficiency in medication management.
The facility failed to maintain professional standards for food safety, with staff not adhering to proper hand hygiene and food handling practices. Observations included improper glove use, lack of handwashing, and inadequate food storage and labeling. Additionally, the kitchen environment was not kept sanitary, with unclean surfaces and improper dishwashing practices.
The facility did not ensure RN coverage for eight consecutive hours daily, as required. Staffing records for May, June, and July 2024 showed specific days without scheduled RN coverage. The Administrator was aware of these lapses and expected appropriate RN coverage.
Failure to Obtain Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform residents and/or their responsible parties in advance of the risks and benefits of proposed care by not obtaining written consent before starting psychotropic medications for two residents. The facility’s policy, dated 5/9/25, stated that prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed in advance of the benefits, risks, and alternatives. Review of the records showed no consent form on file for either resident regarding psychotropic medication use. One resident had diagnoses including anxiety, depression, schizophrenia, and non-Alzheimer’s dementia, with a significant change in status MDS showing worsening behavior and disorganized thinking. That resident’s medication orders included olanzapine, bupropion, and venlafaxine. The second resident had diagnoses of depression, schizophrenia, and traumatic brain injury, with a care plan noting a communication problem related to the brain injury and dependence on staff for social, intellectual, emotional, and physical needs. That resident’s medication orders included amitriptyline, risperidone, and venlafaxine. During interviews, an LPN was unsure when psychotropic medication consents were needed, and the DON and Administrator stated they had interpreted the policy incorrectly regarding when consents should be signed.
Resident Information Left Visible on Medication Cart Computer
Penalty
Summary
The facility failed to maintain resident privacy and confidentiality of personal and medical records when a CMT left the computer screen on the medication cart open, unlocked, and visible to anyone passing by. The screen displayed confidential resident information while the CMT walked away from the cart and entered resident rooms or the shower room. This was observed for three residents: one resident with mild cognitive impairment, primary hypertension, Type 1 diabetes, limited mobility, fall risk, and acute pain from multiple rib fractures; one resident with visual loss, hypertension, heart failure, anticoagulant and antiplatelet use, blindness-related ADL dependence, and a hearing deficit; and one resident with traumatic brain injury, depression, hypertension, antipsychotic, antidepressant, and anticoagulant use, left-sided paralysis, and a communication deficit. During interviews, the CMT stated he/she knew not to leave the computer screen open with resident information visible while passing medications and should have closed it. An LPN stated the screen is not supposed to be left open when walking away from the medication cart and must be locked or placed on privacy mode. The DON stated staff are not to leave the computer screen open with resident information visible when walking away from the medication cart, and the Administrator stated staff should minimize the screen or shut the laptop before walking away and it should not be left unattended.
Unsafe and Poorly Maintained Environment
Penalty
Summary
The facility failed to provide a safe, comfortable, and homelike environment for all residents, with a census of 46. The facility’s Safe and Homelike Environment Policy stated that the environment must be safe, clean, comfortable, and homelike, and the Resident Environmental Quality Policy stated the building must be equipped and maintained to provide a safe, functional, and comfortable environment. The Handrails Policy stated routine maintenance on handrails would be completed by the maintenance department. During observation, the baseboard heater between two rooms was dented, bent out of shape, and protruded into the hallway, and another baseboard heater between a room and room 213 was also dented, bent out of shape, and protruded into the hallway. The handrail on the right side of the hall outside the dining room was chipped and splintered when touched, a piece of drywall was missing in the hall between two rooms, the handrail between a room and room 207 had missing paint and splintered when touched, and the handrail on the left side of the fire doors had missing paint and splintered when touched. The Maintenance Supervisor stated he was responsible for repairs to the walls, handrails, and baseboard heaters, that all areas of the building should be in good repair, and that he had not had time to complete the needed repairs. The Administrator stated she expected all areas of the building to be in good repair and expected the maintenance department to complete these repairs.
Failure to Complete and Follow Pharmacist Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure monthly drug regimen reviews were completed and acted upon for three residents, and it did not provide the requested policy for Drug Regimen Reviews. The report states that the facility was expected to maintain residents’ highest practicable level of physical, mental, and psychosocial well-being by providing oversight from a licensed pharmacist, including review of the medical chart and follow-up of irregularity reporting. Review of the facility’s psychotropic medication policy showed that residents using psychotropic drugs should receive gradual dose reductions unless clinically contraindicated. For one resident with severe cognitive impairment, dementia, and heart failure, the record showed Seroquel 100 mg at bedtime with no diagnosis listed for use, and the consultant pharmacist noted the antipsychotic lacked an allowable diagnosis; no physician response to the recommendation was found. For another resident with no cognitive impairment and diagnoses including seizure disorder, diabetes, and depression, the pharmacist noted that lab work for a Keppra level was ordered but could not be located, yet no lab order or lab results were found and no physician response was documented. For a third resident with impaired cognition, dementia, anxiety, depression, and schizophrenia, the medication regimen review noted venlafaxine 225 mg daily had been given without a gradual dose reduction, and the pharmacist requested a reason if the reduction could not be completed; the record did not show that the information was sent to the physician or that the physician responded.
Kitchen and Dining Room Not Kept in Good Repair
Penalty
Summary
The facility failed to prepare and serve food in accordance with professional standards when the kitchen and dining room were not kept in good repair. During observation, surveyors found a black substance on the wall behind the sink in the dish area, five broken tiles and two missing tiles under the dishwasher, black stains along the edges of the exit door leading into the dining room and a black area around the door knob, brown substance and black stains on the bottom of the dry storage doors, and seven broken floor tiles under and around the steam table. In the dining room, surveyors observed a cabinet under the sink with missing paint and damaged wood, two ceiling tiles with black rings by the exit door, broken window blinds on all windows, and eight dining room chairs with ripped seats and exposed foam. Resident #13’s quarterly MDS showed no cognitive impairment and supervision with ADLs, with diagnoses including diabetes, high blood pressure, and anemia. The resident’s care plan also indicated the need for supervision with ADLs. During interview, Resident #13 said the broken chairs were uncomfortable to sit in and that it would be nice to have blinds that were not broken to look at during meals. The Maintenance Supervisor stated he was responsible for repairs in the kitchen and dining room, said they should be in good repair, and acknowledged the dining room chairs needed to be replaced because they were torn and uncomfortable. The Administrator stated she expected the kitchen and dining room, including the furniture and window blinds, to be in good repair and clean, and identified the Maintenance Supervisor as responsible for those repairs.
Failure to Reassess PASARR After New Serious Mental Illness Diagnosis
Penalty
Summary
The facility failed to complete a reassessment of the Level I PASARR for one resident when the resident developed a new diagnosis of a serious mental illness. The resident’s Significant Change MDS, completed by facility staff, documented disorganized thinking, difficulty focusing attention, and diagnoses of non-Alzheimer’s dementia, anxiety, depression, and schizophrenia. The resident’s care plan also identified dependence on staff for physical, social, and emotional needs and use of psychotropic and anti-anxiety medications related to mood disorder, schizoaffective disorder, and major depressive disorder. The resident’s admission MDS did not show a diagnosis of schizophrenia at the time it was completed, and the prior Level I PASARR from 2021 indicated no signs or symptoms of a major mental disorder and no need for a Level II screening. However, the current diagnosis report showed schizoaffective disorder with an onset date of 3/28/25. During interview, the Administrator stated the resident had schizoaffective disorder since admission when the initial Level I PASARR was completed, noted that some resident information did not transfer over when the new company took over, and said a new PASARR should have been completed.
Unsecured controlled medication in medication refrigerator
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments under proper temperature controls when three bottles of liquid lorazepam, a schedule IV controlled medication, were found in the medication refrigerator without being secured behind two locks. The facility’s Medication Storage policy, dated 5/9/25, stated that schedule II drugs and back-up stock of schedule III, IV, and V medications are to be stored under double-lock and key. During observation of the medication room on 12/02/2025 at 4:17 P.M., the medication refrigerator containing the three bottles of lorazepam was not locked, the lock for the medication fridge was sitting on a counter in the medication room, and a piece of the locking mechanism on the fridge was not attached to the fridge. In interviews, CMT B said the fridge lock had been broken for awhile and was not sure how long, the Administrator said she was not aware the lock was broken, and later stated that the locking mechanism piece was not attached so the lock would not work. CMT A said he/she did not know the lock was broken, CMT C said he/she had heard the lock was broken, and LPN A said he/she was not sure how long the lock had been broken.
Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of dementia-related behaviors entered another resident's room and physically kicked the other resident in the shin. The incident resulted in pain and redness for the resident who was kicked. The event was not witnessed by staff, but was reported by the affected resident and confirmed by a physical assessment that noted redness on the shin. The resident who initiated the altercation had a documented history of dementia, limited mobility, and was identified as an elopement risk and wanderer. Prior to the incident, this resident had exhibited behaviors such as yelling for family and staff, and had recently experienced acute illness, hospitalization, and increased behavioral symptoms upon readmission. The care plan for this resident included monitoring for behaviors that could pose a danger to self or others, as well as interventions for wandering and aggression. The resident who was kicked was cognitively intact, able to voice concerns, and at risk for impaired skin integrity. The incident was reported to facility administration, and staff responded by removing the aggressive resident from the room and providing immediate care to the injured resident. The facility's policies required staff to monitor for and intervene in situations of potential abuse, but the event still occurred, resulting in physical harm to a resident.
Facility Lacks Qualified Dietary Manager
Penalty
Summary
The facility failed to employ a qualified director of food and nutrition services, which had the potential to affect all 44 residents who received meals prepared in the facility's only kitchen. The Dietary Manager (DM) listed in the facility's Key Personnel was not a Certified Dietary Manager (CDM) as required by the job description. The DM had been in the position since July 2023 and had worked at the facility for ten years as a dietary aide. However, she had not completed a dietary manager's course or any course in food safety and management. The Registered Dietitian (RD), who was not full-time and only consulted monthly, confirmed the DM's lack of qualifications. The RD had recommended that the DM complete a course to become a CDM and offered to be her preceptor. Despite these recommendations, the DM had not pursued the necessary certification. The facility's Administrator also confirmed that the DM had not been in the management position for two years and had not completed the required course to meet regulatory standards.
Resident Altercation Due to Cognitive Impairment and Environmental Triggers
Penalty
Summary
The facility failed to protect a resident's right to be free of physical abuse, as evidenced by an incident involving two residents. Resident 16, who has moderate cognitive impairment and a history of verbal and physical outbursts, was involved in an altercation with Resident 40, who has severe cognitive impairment and a history of potential physical aggression related to dementia. The incident occurred in the dining room when Resident 16 attempted to move Resident 40's walker, leading to Resident 40 striking Resident 16 in the face, causing a minor scratch. Resident 40 had been experiencing delusional behaviors due to a urinary tract infection and was on an antibiotic. The altercation was triggered when Resident 40 felt trapped and reacted aggressively. Staff intervened by separating the residents and calling emergency services. Resident 40 was sent to the hospital for evaluation and later returned to the facility. The incident was reported to the state agency within the required timeframe. The facility's investigation revealed that Resident 40 had a history of yelling and threatening other residents but had not previously engaged in physical contact. The incident highlighted the need for careful monitoring of Resident 40's behavior, especially in situations where he might feel confined or threatened. The facility's policy on abuse and neglect emphasizes the prohibition of resident abuse and the requirement to report any incidents that may adversely affect a resident's health or welfare.
Deficiencies in Insulin Administration and Tube Feeding Orders
Penalty
Summary
The facility failed to ensure that staff was knowledgeable about the proper usage of insulin pens for a resident with diabetes. The resident had a physician's order for Humalog insulin, which requires priming the needle set before administration. However, a Certified Medication Technician (CMT) was observed administering the insulin without priming the needle set, indicating a lack of knowledge about the manufacturer's instructions. Both the CMT and the Director of Nursing confirmed the lack of awareness regarding the need to prime the needle set before administering the insulin. Additionally, the facility failed to ensure that physician orders recorded the volume of tube feeding formula for a resident with a feeding tube. The resident's orders for Isosource, a tube feeding formula, did not specify the volume to be administered, despite a consulting dietitian's request for clarification. The Registered Dietitian confirmed that the orders lacked the necessary volume information and had repeatedly asked for clarification over the past year. The facility's Administrator also confirmed the omission in the physician orders.
Medication Management Deficiency Due to Unsecured Storage and Improper Administration
Penalty
Summary
The facility failed to ensure medications were stored securely and administered properly, leading to a deficiency in medication management. Observations revealed that medications were left unattended in pill cups on dining tables in front of two residents, who did not have orders to self-administer their medications. Certified Medication Technician (CMT) A placed the medications on the tables and left the dining room, contrary to facility policy which requires staff to administer and observe medication intake if residents do not have self-administration orders. Resident #1, who was cognitively intact and independent with eating, was left with medications unattended, despite not having a self-administration order. Similarly, Resident #2, who had moderately intact cognition and required assistance with eating, was also left with medications unattended. Both residents had multiple diagnoses and were on various medications, including antidepressants, anticoagulants, and diuretics, which necessitated careful administration and monitoring by staff. Additionally, the facility failed to secure medication carts, as observed with an unlocked cart labeled 'north hall' left unattended in the lobby area outside the nurse's station. The Assistant Director of Nursing and the Administrator both acknowledged that medication carts should be locked when not in use and that it was inappropriate for staff to leave medications unattended in front of residents. These actions and inactions contributed to the deficiency in medication management at the facility.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple observations of improper hand hygiene and food handling practices. Staff members were observed not washing their hands between tasks, using hand sanitizer instead of washing hands, and failing to change gloves between different tasks. Additionally, there were instances where staff did not wash their hands after handling soiled items or after picking up items from the floor, which could lead to cross-contamination. The facility also did not maintain proper food storage and labeling practices. Spices and other food items were found undated and opened, with some being expired. The facility's policy required that food items be dated when opened to ensure they are discarded appropriately, but this was not consistently followed. Furthermore, the facility failed to maintain accurate temperature logs for refrigerators and freezers, which are crucial for ensuring food safety. Sanitation practices in the kitchen were inadequate, with observations of unclean surfaces, lack of sanitizer solution, and improper storage of dishware. The dishwashing machine was not consistently tested for proper sanitation levels, and there were lapses in maintaining a clean and sanitary kitchen environment. Staff interviews revealed a lack of awareness and adherence to the facility's policies on sanitation and food safety, contributing to the deficiencies observed.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week, as required. The facility census was 47, and there was no policy provided regarding RN staffing. A review of the facility's staffing records revealed that there were specific days in May, June, and July 2024 when no RN was scheduled for the required eight consecutive hours. During an interview, the Administrator acknowledged awareness of the lack of RN coverage on certain days and expressed the expectation that the facility should have the required and appropriate RN coverage.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Oregon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tiffany Heights | 12.1 mi | ★★★★★ | 15 | 0 |
| Laverna Manor Health & Rehabilitation | 17.5 mi | ★★★★★ | 20 | 2 |
| Wathena Healthcare & Rehabilitation Center | 17.8 mi | ★★★★★ | 0 | 0 |
| Abundant Acres Care And Rehab | 20.8 mi | ★★★★★ | 42 | 2 |
| Advanced Care Of St Joseph | 21 mi | ★★★★★ | 2 | 0 |
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