Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avamere Health Services Of Rogue Valley during CMS and state inspections, most recent first.
A resident reported being very cold in the room and wearing multiple layers and socks on the hands at night to stay warm. The room temperature measured well below the expected range, including a cold area near the AC vent. In addition, hot water in a resident restroom and in multiple rooms and a public restroom on the 300 hall measured above the stated 120-degree limit, including readings of 132 degrees and 142 degrees.
An LPN and an RN observed bottles of antifungal powder left unsecured in a precaution cart and in resident rooms on a table and overbed table. Both nurses stated the antifungal powder should be locked in the treatment cart, and the DNS confirmed that it should be stored there.
Staff failed to follow contact precautions for two residents and performed wound care for a resident with a stage 4 coccyx pressure wound in an unsanitary manner. A PT transferred one resident without gown or gloves despite posted PPE signage, and a CNA entered another contact-precaution room without PPE while delivering a tray. An LPN then completed wound care using the same gloves throughout cleaning and dressing the wound and handled a pen from her pocket during the procedure.
A resident with severe cognitive impairment and a care plan requiring denture cleaning did not receive necessary oral care assistance from staff. Family members reported having to clean and insert the resident's dentures themselves, and staff interviews revealed inconsistent awareness and communication regarding the resident's denture care needs. Observations confirmed the resident wore dentures overnight and had mouth odor, indicating a lack of proper oral hygiene support.
Failure to report an allegation of verbal abuse: A resident with alcohol abuse and seizures said an LPN made a belittling comment during delivery of a NOMNC, stating, "This isn't a homeless shelter." The resident emailed the administrator with a formal complaint about the staff conduct, but the complaint was not fully investigated or reported to the State Agency because the staff member was not identified.
A resident with alcohol abuse and seizure diagnoses reported that an LPN made a belittling comment during delivery of a NOMNC, saying, "This isn't a homeless shelter." The resident emailed the administrator with a formal complaint, but the allegation of verbal abuse was not investigated because the staff member's name was not clarified, and the administrator later acknowledged the complaint should have been investigated.
Care Plan Not Updated for Resident Behaviors: A resident with dementia had a behavior monitor for agitation, fabricating stories, and anxiety, but the care plan was not updated to reflect later hallucinations, confusion, verbal abuse, sexual threats, death threats, and other changing behaviors. Staff reported triggers such as roommates, meals, TV content, and even the color yellow, and the Social Services Director and DNS confirmed the care plan did not address all current behaviors.
Failure to provide meaningful activities for two residents. One resident with Alzheimer's disease and severe cognitive impairment had documented interests and a care plan for activity support, but CNA task records showed no activities provided and staff observed no interaction. Another resident with Parkinson's disease and intact cognition had documented interests in group activities, but the activity profile was incomplete, no activities were provided, and the resident stated they were bored and did not know where activities were located.
Failure to implement fall precautions for two residents. One resident with stroke, hip fracture, and dementia had a care plan for fall mats on both sides of the bed, but staff repeatedly observed no mats in place and some staff were unaware the intervention was ordered. Another resident with sepsis, respiratory failure, weakness, and disorganized thinking was repeatedly observed lying crosswise in an elevated bed despite a falls care plan for the bed to remain in the lowest position; CNAs reported unsafe positioning and communication gaps with nursing staff.
Failure to address significant weight loss: A resident admitted with falls and MS was on a regular diet but experienced a marked drop in weight over a short period, with a progress note documenting 5.8% weight loss. The resident reported eating very little because the food was “terrible,” and the chart showed no supplements or other interventions in place when staff identified the significant weight loss. Staff later acknowledged the weight loss was significant and that there was a 12-day delay before assessment and nutritional interventions were put in place.
A resident with chronic pain reported moderate to severe pain on multiple days and stated regularly experiencing severe pain. The resident requested lidocaine patches, and the request was documented in the Provider Communications Notebook, but the MD said she was not aware of the request and the DNS could not locate the documentation. The Administrator and DNS confirmed nursing staff should document medication needs in the Provider Communications Notebook and follow up if no provider response is received.
A resident with dementia had ongoing problems with loose upper dentures that affected meals and caused self-consciousness. Records showed the diet was downgraded, the resident avoided meals at times because of denture trouble, and staff noted the dentures had been loose since admission. Social services attempted to arrange a dental appt, but staff confirmed there was a delay in getting it scheduled.
The facility failed to address grievances raised by the resident council, including issues with staff respect, response times, follow-up on concerns, perceived retaliation, call light delays, noise levels, lack of snacks, poor food quality, lost items, insufficient activities, and untimely showers. The Activity Director did not forward the completed grievance form, and the Administrator did not receive it, resulting in unmet needs for the residents.
The facility failed to maintain a homelike environment, with observations of missing floorboards, damaged walls and doors, non-functional lights, unsafe furniture, moldy ceiling tiles, and tattered carpets held together with tape. These issues were acknowledged by the Administrator and Maintenance Director.
The facility failed to maintain water temperatures below 120°F in three resident bathrooms and did not follow or reassess fall prevention measures for a resident who experienced 30 falls. The resident's room was located at the end of the unit with minimal staff activity, and the facility did not implement new interventions despite the resident's high fall risk.
The facility failed to handle and prepare food in a sanitary manner, with observations of dirty coffee pots, improper temperature control of potato salad, and a dietary aide not following proper hand hygiene and glove use, as well as not wearing appropriate beard restraint.
The facility failed to ensure residents received medications as prescribed, were monitored for medication side effects, and provided wound care as ordered. One resident did not receive daily monitoring for anticoagulant and antidepressant medications, another did not receive prescribed Folic Acid, and two residents did not receive wound care as ordered, leading to worsened conditions.
The facility failed to provide adequate staffing, resulting in long call light wait times and unmet care needs for residents. Multiple residents reported waiting from 10 minutes to over an hour for assistance, leading to incontinence episodes and falls. Staff confirmed the facility was often short-staffed, causing delays in care and supervision.
The facility failed to post accurate and complete staffing information from 11/23/23 through 12/15/23. A review of the Direct Care Staff Daily Reports (DCSDR) revealed missing staff hours on eight days, census documented only one day, and the number of staff not documented on two days. The Administrator and DNS were unaware of these issues, and the DNS noted that the Staffing Coordinator was new during this period.
A resident with mild dementia was prescribed Seroquel without proper assessment or rationale, leading to its discontinuation after one dose. The resident experienced falls and confusion, but staff did not document behaviors warranting psychotropic medication use. The facility failed to consult the resident's neurologist for medication management, and non-pharmacological interventions were not adequately explored.
A resident with pernicious anemia reported feeling dismissed and hurt by a nurse's response when inquiring about medication timing. The nurse's dismissive comment and the lack of reporting by another staff member led to the deficiency.
The facility failed to assess a resident for a significant change in condition after the resident, admitted with infection and a pressure ulcer, started hospice services. An LPN confirmed that a required Significant Change MDS was not completed.
The facility failed to update a resident's care plan to reflect the use of a walkie talkie and call bell system for requesting assistance, despite multiple staff confirmations and an alert note indicating the call light was ineffective due to the room's location. This oversight placed the resident at risk for unmet needs.
A resident with pernicious anemia did not receive their required daily vitamin B12 medication due to a delay in pharmacy documentation and delivery. The resident, who was cognitively intact and had severe spinal cord degeneration, reported the missed dose, which was confirmed by staff.
The facility failed to maintain a medication error rate below 5%, resulting in a 7% error rate. One resident received levothyroxine with food instead of on an empty stomach, and another resident did not receive their Cranberry D-Mannose supplement due to a supply oversight.
The facility failed to follow menus for two residents, leading to unmet food preferences. One resident with diabetes received scrambled eggs instead of poached eggs and no drinks, while another resident with adult failure to thrive received incorrect breakfast and lunch items, including missing a hash brown patty and chocolate ice cream.
A resident with diabetic neuropathy and at nutritional risk did not receive necessary adaptive equipment during meals. The resident's care plan required a two-handle cup and a lip plate, but these were not consistently provided, leading to unmet needs. Staff acknowledged the oversight.
A facility failed to ensure accurate medical records for a resident with high blood pressure. Despite physician orders to document blood pressure before administering lisinopril, staff marked 'NA' on multiple dates in the MARs, admitting that readings were taken but not recorded. This oversight placed the resident at risk for inappropriate treatment.
The facility failed to monitor antibiotic use for a resident with a history of MDRO and chronic urinary tract infections. The resident was prescribed cephalexin without a culture and sensitivity test, and an antibiotic time-out was not completed as required.
A resident with kidney failure and difficulty walking reported multiple instances of staff yelling and refusing care, including derogatory comments and denial of medications, leading to the resident leaving the facility AMA. The involved staff were suspended, and an investigation confirmed the resident's claims.
The facility failed to resolve grievances for two residents. One resident's concerns about food being thrown away were not addressed, and another resident's request to avoid care from a specific LPN was ignored, leading to continued care by the LPN despite safety concerns.
The facility failed to protect a resident from abuse when another resident, with a history of physical aggression, yanked their hair after a verbal altercation. Despite staff intervention, the incident highlighted a lapse in ensuring resident safety.
The facility failed to maintain healthy nutritional parameters for three residents, leading to significant weight loss and inadequate nutritional intake. One resident experienced an 8% weight loss without a follow-up Nutritional Assessment, another had severe malnutrition with inconsistent weight documentation, and a third had inadequate meal intake with minimal documentation of nutritional interventions.
The facility failed to maintain ongoing communication with the dialysis center for a resident with chronic kidney disease, resulting in a nearly month-long gap in documentation. This lapse was confirmed by an LPN and the DNS, who could not provide the missing forms.
Unsafe Room Temperatures and Excessively Hot Water
Penalty
Summary
The facility failed to provide a safe and comfortable environment for one resident and for two of three halls reviewed for environment. One resident stated the room was very cold and reported wearing two pairs of socks, sweatpants, a sweatshirt, and socks on the hands at night to stay warm. The resident was observed sitting in a wheelchair with a blanket around the shoulders, and a staff member entered the room and asked whether the resident was still cold. The Maintenance Director stated resident room temperatures were checked weekly and expected to be between 72 and 78 degrees. When the room temperature was checked, it measured 64 degrees and 65 degrees, and the area around the air conditioner vent measured 54 degrees. The Administrator acknowledged the temperature in the resident's room. The report also identified unsafe hot water temperatures in resident and public restroom areas. In one resident room, the restroom hot water became very hot within 10 seconds when turned on, and the resident confirmed not going into the restroom. The Maintenance Director stated hot water in resident rooms was not to exceed 120 degrees and that he checked five resident rooms per week. The water temperature in that room measured 132 degrees. The Administrator stated the water temperature should not exceed 120 degrees. Later, the Maintenance Director checked water temperatures in multiple rooms and the public restroom on the 300 hall, and the temperature was found to be 142 degrees.
Unsecured Antifungal Powder Found in Resident Areas
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles when antifungal powder was found unsecured in multiple locations. On 8/18/25 at 12:13 PM, Staff 18 (LPN) observed a bottle of antifungal powder in an unlocked precaution cart outside a resident room, and stated it should be locked in the treatment cart. On 8/19/25 at 11:05 AM, Staff 18 observed the same type of antifungal powder in a resident room on a small table near the bed, and again stated it should be locked in the treatment cart. On 8/21/25 at 8:28 AM, Staff 16 (RN) observed a bottle of antifungal powder in a resident room on the overbed table, and stated it should be locked in the treatment cart. Later that morning, Staff 2 (DNS) stated antifungal powder should be locked in the treatment cart.
Failure to Follow Contact Precautions and Maintain Sanitary Wound Care
Penalty
Summary
The facility failed to ensure staff followed transmission-based precautions for residents on contact precautions and failed to provide wound care in a sanitary manner for Resident 47. On 8/18/25, signage outside one resident’s room instructed staff assisting the resident in Bed A to wear gowns and gloves during high-contact activities, including transfers, but a PT transferred the resident from bed to wheelchair without wearing a gown or gloves and stated she did not wear PPE because she did not handle the resident’s catheter. Staff 19, the IP, stated therapy staff were provided a list of residents on transmission-based precautions and were expected to reference the list and follow the posted signage for appropriate PPE use. Also on 8/18/25, a CNA entered another room on contact precautions without a gown or gloves while delivering a tray, despite the sign indicating staff were to wear a gown and gloves upon entering the room. The CNA acknowledged the sign and stated she did not wear PPE because she did not touch the resident. Resident 47 was admitted in 8/2023 with depression and had a stage 4 pressure wound on the coccyx present on admission. During observed wound care, an LPN completed hand hygiene, donned a gown and gloves, set up supplies on the resident’s bed, and while wearing the same gloves cleaned the wound, applied the dressing, retrieved a pen from her pocket to date and sign the dressing, and returned the pen to her pocket. The LPN stated she did not change gloves during the wound care and that this was how she always completed wound care.
Failure to Provide Denture and Oral Care Assistance
Penalty
Summary
A resident with diagnoses including COPD and dementia, and a BIMS score indicating severe cognitive impairment, was admitted to the facility and required set-up assistance for oral hygiene. The resident's care plan specified that oral care should include cleaning full upper and partial lower dentures. Despite these documented needs, family members reported that during a 72-hour stay, they had to clean and insert the resident's dentures themselves because staff did not provide assistance. Observations confirmed the resident had mouth odor and admitted to wearing dentures overnight, contrary to care plan instructions. Staff interviews revealed inconsistent awareness and implementation of the resident's oral care needs. One CNA stated there was a note in the resident's room to ensure denture care, but acknowledged finding the dentures in the resident's mouth in the mornings and did not inform nursing staff of the issue. Another CNA was unaware the resident wore dentures, despite assisting with oral care in the evenings. The LPN-Resident Care Manager confirmed that dentures were to be cleaned in the morning and evening and removed at night, and expected staff to communicate care concerns to ensure proper oral hygiene. These findings indicate a failure to provide necessary assistance with oral care as required by the resident's care plan.
Failure to Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of verbal abuse to the State Survey Agency for 1 resident who was admitted in 6/2025 with diagnoses including alcohol abuse and seizures. During an interview on 8/18/25, the resident stated that while receiving a NOMNC from the Social Service Director and an LPN Infection Preventionist, the nurse told the resident, "This isn't a homeless shelter." The resident said the comment felt belittling and reported the concern to the administrator by email, but did not receive a response. Record review showed the resident sent an email on 8/7/25 titled "Formal Complaint Regarding Improper Notice, Coercion, and Staff Conduct," stating that during the NOMNC the nurse made the homeless shelter comment and smirked without responding when asked if the resident was being called homeless. The administrator replied that he would address the concern and asked for the nurse's name, but the resident did not provide it. The administrator later stated he received the complaint, did not complete an investigation because the resident did not identify the staff member, and acknowledged that the email was an allegation of verbal abuse that should have been reported to the State Agency.
Failure to Investigate Allegation of Verbal Abuse
Penalty
Summary
The facility failed to investigate an allegation of verbal abuse involving one resident who was admitted in 6/2025 with diagnoses including alcohol abuse and seizures. The resident stated that during receipt of a NOMNC from the Social Service Director and an LPN Infection Preventionist, the nurse told the resident, "This isn't a homeless shelter," and the resident felt belittled by the comment. The resident reported the concern to the administrator by email but did not receive a response. Record review showed the resident sent a formal complaint email on 8/7/25 describing the comment as demeaning and unprofessional. The administrator replied that he would address the concern with the staff member involved, but he did not complete an investigation because the resident did not provide the staff member's name. The administrator later acknowledged that the email was an allegation of verbal abuse and that the allegation should have been investigated to rule out abuse.
Care Plan Not Updated for Resident Behaviors
Penalty
Summary
The facility failed to ensure Resident 6’s care plan was revised to reflect resident-centered care for behaviors. Resident 6 was admitted in 3/2025 with diagnoses including dementia. A comprehensive care plan dated 5/21/25 identified a behavior monitor for agitation, fabricating stories, and anxiety, with triggers listed as growing up in an alcoholic environment, dealing with physical and mental changes, and roommate issues; however, there was no additional behavior care plan. Subsequent records documented worsening and changing behaviors, including hallucinations, confusion, argumentative behavior with CNA staff, verbal behaviors toward others, calling out, difficulty sleeping, agitation with staff, other residents, and around meals, as well as television noise and commercials as triggers. The resident also made comments about hitting and raping staff, accused staff of trying to kill him/her, and made death threats toward staff. Additional documentation showed the resident was triggered by seeing the color yellow and continued to display escalating verbal and sexual threats. During interviews, Resident 6 made multiple statements about killing others, and staff reported the resident threatened staff, became upset if staff were not immediately present, made derogatory statements toward women, and was affected by television content. Staff also stated the resident made sexual comments and that certain TV shows influenced behavior. The Social Services Director reviewed the care plan and stated it did not address all of the resident’s behaviors, and the DNS confirmed it would be appropriate for the care plan to address the resident’s current behaviors.
Failure to Provide Meaningful Activities
Penalty
Summary
The facility failed to provide meaningful activities for 2 of 3 sampled residents reviewed for activities. Resident 2 was admitted with diagnoses including Alzheimer's disease and stroke. The admission MDS indicated a BIMS score of 2, that it was important to the resident to have things to read, do favorite activities, and get outside when the weather was good, and that activities were to be encouraged related to cognitive impairment with staff anticipating needs. The care plan stated the resident required assistance to attend activities and in-room materials as indicated, with interests including engineering shows, technology reading materials, table games, gardening, and music. However, review of CNA task records showed no activities were provided, and the resident was observed sitting in the hall in a wheelchair with no activity or staff interaction. Staff stated the resident had behaviors, no activities were offered, and the Activities Director acknowledged lacking understanding of appropriate activities for residents with dementia and lacking time for one-on-one interactions without CNA assistance. Resident 67 was admitted with diagnoses including Parkinson's disease and sepsis. The admission MDS indicated a BIMS score of 15, and that books, music, news, and getting outside when the weather was good were very important to the resident. The care plan indicated interest in joining group activities and listed interests including gardening, reading, exercise classes, music, and videos, but the activity profile left likes and dislikes for group and individual activities and exercise preferences blank. Review of CNA task records showed no activities were provided, and the resident was observed sitting in the room with no television on and stated being bored and waiting to go home. The resident said they were open to attending activities if invited and did not know where activities were located. Staff acknowledged the activity assessment was incomplete, that the resident needed additional staff engagement for socialization and activities, and that staff were unsure where to chart activities.
Failure to Implement Fall Precautions for Two Residents
Penalty
Summary
The facility failed to implement fall precautions for two residents who were reviewed for accidents. One resident was admitted with diagnoses including stroke, hip fracture, and dementia, and an 8/13/25 revised care plan directed staff to place fall mats on each side of the bed because the resident was at high risk for falls. However, the resident was observed in bed without fall mats at the bedside on 8/19/25 and again on 8/22/25. The resident’s family stated fall mats were not being used, a CNA said she was unaware the mats were indicated in the care plan, and an LPN stated she was not aware the resident was supposed to have fall mats because it was not on the TAR. The resident care manager and DNS stated staff were expected to use the fall mats as indicated in the care plan. The second resident was admitted with diagnoses including sepsis and respiratory failure. A falls care plan directed staff to keep the bed in the lowest position except during care, and the admission MDS indicated the resident had generalized weakness, some disorganized thinking, a BIMS score of 14, and was dependent on staff for toileting. The resident was observed lying crosswise on the bed with the bed elevated on 8/19/25, and again on 8/22/25 with the bed elevated and the resident positioned across the bed with feet within one foot of the floor. A CNA stated the resident often positioned self in unsafe ways and refused to keep the bed low, while another CNA said he had told nurses several times about concerns with the resident’s positioning in bed. Staff confirmed nursing staff were not informed, and the DNS stated the care plan had not been updated to address the resident’s bed placement and needed revision to address fall risk interventions.
Failure to Address Significant Weight Loss
Penalty
Summary
The facility failed to maintain a healthy nutritional status for one resident who was reviewed for nutrition. The resident was admitted with diagnoses including falls and Multiple Sclerosis and had a physician order for a regular diet. The resident’s weights showed a decline from 131.8 lbs. on 8/4/25 to 128 lbs. on 8/5/25, then to 123.6 lbs. on 8/11/25 and 124.2 lbs. on 8/12/25. A progress note on 8/13/25 documented a 5.8% weight loss. During interview, the resident stated not eating much because the food was “terrible” and was unsure whether weight had been lost. The medical record showed no evidence of supplements or other interventions for weight loss. Staff interviews confirmed the resident had a poor appetite at times, that the weight loss was significant, and that no interventions or supplements were in place at the time the weight loss was identified. The resident was to be discussed in the Nutrition at Risk meeting, and staff acknowledged there were 12 days between the significant weight loss and the assessment and implementation of interventions.
Pain Management Request Not Followed Through
Penalty
Summary
Provide safe, appropriate pain management for a resident who requires such services was not met for Resident 10, who was admitted in 2017 with diagnoses including chronic pain. A 7/9/25 progress note documented that the resident requested lidocaine patches to manage pain, and the same request was also documented in the Provider Communications Notebook by Staff 22, the former LPN-Resident Care Manager. A review of the 8/2025 Pain Level Summary showed Resident 10 reported pain levels of 3 to 6, described as moderate to severe, on 9 of 21 days reviewed. On 8/19/25, the resident stated regularly experiencing severe pain. On 8/21/25, the Medical Director stated she was not aware the resident had requested lidocaine patches, and on 8/22/25 the DNS stated she was unable to locate documentation of the request in the Provider Communications Notebook. The Administrator and DNS confirmed nursing staff should document residents' medication needs in the Provider Communications Notebook and follow up if they do not receive a response from the provider.
Failure to Obtain Routine Dental Services for Resident with Loose Dentures
Penalty
Summary
The facility failed to obtain routine dental services for one resident who was admitted in 1/2025 with dementia and had ongoing problems with upper dentures that did not fit properly. Progress notes documented that the resident’s diet was downgraded because of loose dentures, that the resident did not want to get up for meals because of trouble with the dentures, and that the resident did not want others to see the top dentures because they fell down while eating. The care plan noted the resident wore upper dentures, and later social services documentation showed an attempt to make a dental appointment, while a care conference note recorded the resident’s concern about the dentures not fitting and an upcoming dental appointment. During observation, the resident was seen eating in the room with dentures that appeared to not fit well and moved while talking and eating. Staff interviews confirmed the resident had been self-conscious about the dentures, that the dentures had been loose since admission, and that there was a delay in arranging the dental appointment.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to address grievances raised by the resident council, as evidenced by the Bi-Monthly Resident Counsel Questions form completed on 4/10/24. The form highlighted several concerns, including residents not feeling respected by staff, staff not listening to or responding to their needs timely, and staff not following up on concerns. Additional issues included perceived staff retaliation, delayed call light responses, unacceptable noise levels, lack of bedtime snacks, poor food quality, lost items not being replaced, insufficient activities, and untimely showers. During a resident council meeting on 4/17/24, residents reiterated that these concerns had not been addressed by the facility staff. On 4/19/24, the Activity Director (Staff 21) confirmed that the Bi-Monthly Resident Counsel Questions form process was initiated on 4/10/24 but admitted she did not forward the completed form to anyone. The Administrator (Staff 1) also confirmed that he did not receive a copy of the form and acknowledged that grievances should be addressed within five days. The failure to forward and address the grievances resulted in unmet needs for the residents, as the concerns raised on 4/10/24 were not acted upon by the facility staff.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment, as evidenced by multiple observations of unkempt and unsafe conditions. Specific issues included a missing floorboard in one room, a bathroom door with a large chunk missing, and wall damage with missing paint in several rooms. Additionally, lights were not working in the 200 hall, and a small round table in the smoking area had sharp and jagged edges. The double doors at the end of the 100 hall were covered with cobwebs, residual tape, and splatter marks. A ceiling tile outside one room was damaged and appeared to have mold. The transition strip in the large dining room was torn and peeling, and the carpet in various areas of the facility was tattered and held together with black tape. Further observations revealed that the carpet along the entryway where mechanical lifts were stored was torn and tattered, and there were gaps along the transition strip. The nurse's station on Hall 100 had approximately three to four feet of tattered carpet, and Hall 200 had two areas near the fire doors and the nurse's station with black tape holding the carpet together. The main entryway had a large section of loose carpet with waves and wrinkles. These issues were acknowledged by the Administrator and the Maintenance Director, indicating a need for addressing these concerns to ensure a safe and homelike environment for the residents.
Failure to Maintain Safe Water Temperatures and Implement Effective Fall Prevention Measures
Penalty
Summary
The facility failed to maintain water temperatures below 120°F in three resident bathrooms, with temperatures recorded at 123°F, 125°F, and 121°F. This issue was identified during an inspection with the Maintenance Lead, and the Administrator acknowledged the problem, indicating that the water heater was new and adjustments would be made. Residents in these rooms required varying levels of assistance for toileting, placing them at risk of injury due to the elevated water temperatures. Additionally, the facility failed to follow care plan interventions, assess for care plan effectiveness, and implement new fall interventions for a resident admitted in August 2023 with diagnoses including infection and pressure ulcer of the lower spine. The resident, who had no cognitive impairments initially but later developed moderate cognitive impairments, experienced 30 falls from October 2023 to April 2024. Despite multiple falls, the facility did not consistently implement new fall prevention measures or reassess the effectiveness of existing interventions. Observations revealed that the resident's room was located at the end of the unit with minimal staff activity, and the resident did not use the call light for assistance. Staff interviews confirmed that the resident was a high fall risk and would benefit from being closer to the nurses' station, but no appropriate beds were available. The facility's failure to adequately supervise the resident and reassess fall prevention measures placed the resident at continued risk of falls and potential injury.
Failure to Maintain Sanitary Food Handling Practices
Penalty
Summary
The facility failed to handle and prepare food in a sanitary manner, as observed during a survey. On the morning of the survey, dirty coffee pots were noted on the beverage carts for two wings, which were acknowledged by the Dietary Services Manager as needing deep cleaning. During lunch preparation, a dietary aide was observed performing a temperature check on all food, finding the potato salad at 51 degrees instead of the required 41 degrees, but no further action was taken to address this. The dietary aide also failed to maintain proper hand hygiene and glove use, touching various surfaces and his face without changing gloves or washing hands, and did not wear appropriate beard restraint, leading to potential contamination of food items. The dietary aide was seen handling food with both utensils and gloved hands, leaving the steam table multiple times to retrieve items from the refrigerator without changing gloves or performing hand hygiene. He also touched his nose and watch, and discarded a glove on top of a tote containing uncovered potato salad. The aide acknowledged the break in infection control practices, including the need to change gloves, perform hand hygiene, wear a beard restraint, and recheck the temperature of the potato salad before serving it to residents.
Failure to Administer Medications and Provide Wound Care as Ordered
Penalty
Summary
The facility failed to ensure residents received medications as prescribed, were monitored for medication side effects, and provided wound care as ordered. Resident 8, who was admitted with diagnoses including depression and irregular heartbeat, had no documentation in clinical records indicating daily monitoring of side effects for anticoagulant and antidepressant medications. Staff acknowledged that such monitoring should be in the physician's orders and conducted daily, but it was not done for Resident 8. Resident 52, admitted with a diagnosis of pernicious anemia, did not receive prescribed Folic Acid from 4/13/24 through 4/16/24. Progress notes indicated the medication was on order and waiting for pharmacy delivery, but it was later revealed that Folic Acid was available in the central supply closet and should have been administered. This oversight resulted in a failure to provide necessary medication for the resident's condition. Resident 58, admitted with an infection in a right foot wound, did not receive wound care as ordered on 8/24/23 and 8/25/23. The wound care was passed to the next shift but not completed, leading to maggots being found in the wound and increased redness. Similarly, Resident 59, with a pressure injury to the sacrum, had missed wound care documentation on 5/19/23 and 5/20/23. Staff 15 was accused of falsifying records by signing that wound care was completed when it was not. The facility acknowledged the missed documentation and the failure to complete wound care as ordered for both residents.
Inadequate Staffing and Long Call Light Wait Times
Penalty
Summary
The facility failed to have adequate staff available to timely meet the needs of residents, as evidenced by multiple instances of long call light wait times and unmet care needs. Residents reported waiting from 10 minutes to over an hour for assistance, particularly during the evening and night shifts. Several residents experienced incontinence episodes and falls due to the lack of timely response from staff. Interviews with residents and staff confirmed these delays, with staff acknowledging the facility was often short-staffed and overwhelmed, leading to inadequate care and supervision. Resident 32, who was admitted with diagnoses including stroke and dementia, was left in a soiled brief for extended periods due to insufficient CNA staffing. The facility failed to meet state minimum staffing requirements on several occasions, and a public complaint highlighted that Resident 32's family member observed the resident sitting in a wet brief because staff were not available to assist. Staff confirmed the resident's complaints about long wait times and inadequate care. Resident 60, admitted with diagnoses including anxiety and a pressure ulcer, also experienced significant delays in care. The resident called the police for help after being left in urine and unable to reach staff. Documentation revealed gaps in care, and a public complaint indicated the resident had to call a family member and 911 for assistance. Staff confirmed the facility was short-staffed, leading to long call light wait times and residents' needs not being met. Additionally, Resident 160, who required assistance with toileting, reported waiting 45 minutes for help and observed staff ignoring call lights. Staff confirmed that a former CNA had a history of not answering call lights and was eventually terminated for these issues.
Failure to Post Accurate and Complete Staffing Information
Penalty
Summary
The facility failed to post accurate and complete staffing information, as required, for the period from 11/23/23 through 12/15/23. A review of the Direct Care Staff Daily Reports (DCSDR) revealed that no staff hours were documented on eight days, the census was documented only one day, and the number of staff was not documented on two days out of the 23 days reviewed. On 4/19/24 at 7:39 AM, the Administrator and the Director of Nursing Services (DNS) stated they were unaware of the issues with the DCSDR reports. The DNS mentioned that the Staffing Coordinator was newer to the facility during the reviewed time period.
Failure to Assess and Document Rationale for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents were properly assessed before the prescription and use of psychotropic medications. Specifically, Resident 29, who was admitted with a diagnosis of mild dementia without behaviors, was prescribed Seroquel without an assessment or rationale documented in the clinical record. The resident's progress notes indicated that the resident was alert, oriented, and adjusting well to the facility environment, with no unwanted behaviors noted. Despite this, Seroquel was added to the resident's medication regimen, and the resident's daughter was not informed of the rationale for this decision, leading to the medication being discontinued after one dose. Subsequent progress notes revealed that Resident 29 experienced several falls and exhibited some confusion but was easily redirected by staff. The resident's clinical record did not contain any assessments or rationales for the initiation of Seroquel or Nuplazid, another psychotropic medication started later. Interviews with staff and the resident's family confirmed that there was no documentation of behaviors that would warrant the use of these medications, and the resident's neurologist was not consulted for medication management despite the resident's Parkinson's disease diagnosis. The facility's failure to document assessments and rationales for the use of psychotropic medications placed Resident 29 at risk for over-sedation and other potential adverse effects. Staff acknowledged the lack of documentation and were unable to provide additional information to justify the use of these medications. The resident's condition, including falls and confusion, was not clearly linked to the need for psychotropic medication, and non-pharmacological interventions were not adequately explored or documented prior to the initiation of these medications.
Failure to Treat Resident with Dignity
Penalty
Summary
The facility failed to ensure residents were treated with dignity, as evidenced by the experience of one resident who was admitted with a diagnosis of pernicious anemia. The resident, who was cognitively intact, reported feeling ill for up to four hours after taking a necessary medication and preferred to take it in the morning. On one occasion, when the resident asked a nurse about the timing of the medication, the nurse responded dismissively, stating she would administer it when she wanted to. This response hurt the resident's feelings and made them feel like an inconvenience. Staff interviews revealed that the nurse involved denied any verbal interactions about administering the medication on her time. Another staff member confirmed that the resident had reported feeling spoken to in an undignified manner but did not report it to management, believing it was not verbal abuse. The Director of Nursing Services stated that any such reports should be investigated and staff educated as needed. The nurse involved eventually acknowledged making the dismissive comment to the resident.
Failure to Assess Significant Change in Condition
Penalty
Summary
The facility failed to assess a resident for a significant change in condition. Resident 6, who was admitted in August 2023 with diagnoses including infection and a pressure ulcer of the lower spine, was referred to hospice services on December 14, 2023, and started hospice services on December 20, 2023. However, a review of the resident's Minimum Data Set (MDS) records indicated that a Significant Change MDS was not completed after the resident began hospice services. This was confirmed by Staff 19, an LPN Unit Manager, during a review of the MDS records on April 18, 2024.
Failure to Update Care Plan for Resident's Communication Needs
Penalty
Summary
The facility failed to ensure care plans were revised to accurately reflect the needs of a resident. Resident 7, who was admitted in October 2017 with diagnoses including diabetes and major depressive disorder, had a care plan initiated on September 20, 2023, which instructed the resident to use a call light, walkie talkie, or phone to call the nurses' station if assistance was needed. However, a quarterly MDS assessment in February 2024 revealed that the resident was cognitively intact, and a Kardex dated April 15, 2024, indicated that staff should encourage the resident to use the call light for needs. Despite this, an alert note from March 18, 2024, indicated that the resident was reminded to use the call bell system or walkie talkie because the call light could not be seen or heard from the hall where the resident's room was located. Multiple staff members confirmed that the resident used a walkie talkie or call bell system for assistance, as the call light was ineffective due to the room's location. On April 18, 2024, the LPN Unit Manager reviewed Resident 7's care plan and acknowledged that it did not accurately reflect the resident's current method of calling for assistance. The Director of Nursing Services (DNS) also confirmed that the resident was instructed not to use the call light and to use the other provided devices for staff assistance. The DNS stated that care plans should be updated with any changes, indicating a failure to revise the care plan to reflect the resident's actual needs and methods for requesting assistance. This oversight placed the resident at risk for unmet needs due to the outdated care plan instructions.
Failure to Administer Required Medication
Penalty
Summary
The facility failed to ensure a resident's medication was available for administration, specifically for a resident diagnosed with pernicious anemia. The resident, who was cognitively intact and had severe spinal cord degeneration due to a vitamin B12 deficiency, reported that the facility did not have their required daily vitamin B12 medication available. The medication was not administered on one occasion, and staff noted that the pharmacy did not send the medication because it was not common to administer it daily. The initial order clarification was not documented by the pharmacy, leading to a delay and a missed dose of the medication.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5%, resulting in a 7% error rate with two errors in 27 opportunities. One deficiency involved Resident 303, who was admitted with a diagnosis of a low-functioning thyroid. The resident's levothyroxine, which should be taken 15 to 60 minutes before breakfast, was administered with food. The resident, who was cognitively intact, confirmed that at home, they took the medication on an empty stomach. The LPN Unit Manager acknowledged that while administering levothyroxine with food might be acceptable for long-term residents, it might not be therapeutic for short-term residents like Resident 303. No scientific data was provided to support the practice of administering levothyroxine with food. Another deficiency involved Resident 30, who was admitted with a diagnosis of diabetes. The resident did not receive their Cranberry D-Mannose supplement because it was not available in the supply closet. The LPN responsible for administering the medication stated that they did not see the supplement on the higher shelf in the supply closet. Upon review, the supplement was found in the supply closet, indicating a failure in proper medication administration and inventory management.
Failure to Follow Menus for Two Residents
Penalty
Summary
The facility failed to ensure menus were followed for two residents, leading to unmet food preferences. Resident 8, who was admitted in 2018 with a diagnosis of diabetes, received scrambled eggs instead of poached eggs and did not receive any drinks as per the breakfast menu ticket on 4/17/24. The resident expressed dissatisfaction with the meal provided. Staff 1 (Administrator) and Staff 2 (DNS) confirmed that the kitchen was expected to provide the food items listed on the menu ticket for Resident 8. Resident 40, admitted in 2023 with a diagnosis of adult failure to thrive, also experienced issues with meal accuracy. On 4/17/24, Resident 40 received tater tots instead of the requested hash brown patty and did not receive bacon, which was not on the breakfast meal ticket. Additionally, during lunch, Resident 40 received a hamburger with a bun instead of an English muffin and did not receive the requested chocolate ice cream. Staff 1 and Staff 2 acknowledged that the kitchen should have provided the items listed on the meal ticket and noted that hash brown patties could have been made using tater tots if they were unavailable.
Failure to Provide Assistive Devices for Resident
Penalty
Summary
The facility failed to provide assistive devices for a resident with diabetic neuropathy, who was at nutritional risk and required adaptive equipment such as a two-handle cup and a lip plate. On multiple occasions, the resident did not receive the necessary adaptive equipment with their meals. Specifically, during breakfast, the resident did not receive a drink because the cup provided did not have adaptive handles, and during lunch, the resident was given a cup without adaptive handles. Staff acknowledged that the kitchen neglected to provide the required adaptive equipment as indicated in the resident's care plan and menu tickets.
Failure to Document Blood Pressure Readings
Penalty
Summary
The facility failed to ensure accurate medical records for a resident admitted in December 2023 with a diagnosis of high blood pressure. The physician's order required the resident to receive lisinopril daily, with specific instructions to hold the medication if systolic blood pressure was below 110 or diastolic blood pressure was below 60. However, the resident's Medication Administration Records (MARs) for March and April 2024 showed blood pressure readings marked as 'NA' on multiple dates. Upon review, staff admitted that blood pressure readings were taken but not documented as required. This failure to document the readings accurately placed the resident at risk for inappropriate treatment.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to monitor antibiotic use for a resident with a history of multi-drug-resistant organisms (MDRO) and chronic urinary tract infections. The resident was admitted in July 2013 and had an order for cephalexin, an antibiotic, from February 17, 2024, to February 25, 2024, for a urinary tract infection. A urine analysis on February 16, 2024, indicated a small number of bacteria, but no culture and sensitivity test was completed to determine the appropriate antibiotic. The Director of Nursing Services (DNS) acknowledged that an antibiotic time-out, which should have occurred 48 hours after starting the antibiotic, was not completed.
Failure to Treat Resident with Respect and Dignity
Penalty
Summary
The facility failed to treat a resident with respect and dignity, as evidenced by multiple instances of staff yelling at the resident and refusing to assist with care. The resident, who was admitted in 2023 with diagnoses including kidney failure and difficulty walking, was cognitively intact according to an Admission MDS. On one occasion, the resident asked for a shower and was told by a CNA to wait, followed by derogatory comments about the resident's weight and questioning why the resident was in the facility. The resident also reported being called a derogatory name and being dismissed by a nurse when the issue was raised. Additionally, the resident left the facility against medical advice (AMA) after being denied medications upon return from a dialysis appointment. The resident expressed concerns about dying without the medications, to which an LPN responded dismissively. The incident led to the suspension of the involved staff members, although some staff did not recall the events as described by the resident. The facility's management was notified, and an investigation was conducted, confirming the resident's departure AMA due to the staff's behavior.
Failure to Resolve Resident Grievances
Penalty
Summary
The facility failed to ensure grievances were resolved or resolutions sustained for two residents. Resident 7, who was admitted with diagnoses including type 2 diabetes and major depressive disorder, expressed concerns about nursing staff throwing away her/his food without permission. Despite submitting grievances often via emails to the Administrator, no grievance was initiated or completed regarding this specific concern. This indicates a failure in the facility's grievance handling process as outlined in their policy dated 5/2000, which mandates prompt action on grievances received from residents and their families. Resident 29, admitted with a diagnosis of dementia, had a grievance submitted by a family member requesting that a specific night shift LPN not work with the resident due to safety concerns. Despite this request and a plan to ensure the resident felt safe, the LPN continued to provide care and administer medications to Resident 29, as documented in the clinical records. This failure to adhere to the grievance resolution plan placed the resident at risk and demonstrated non-compliance with the facility's grievance policy.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure residents were free from abuse, as evidenced by an incident involving Resident 19 and Resident 1. Resident 19, who was admitted in August 2020 with post laminectomy syndrome and was cognitively intact as per an 8/22/23 MDS, was subjected to physical aggression by Resident 1 on 9/9/23. Resident 1, who also was cognitively intact according to a 9/13/23 BIMS evaluation, yanked Resident 19's hair after Resident 19 ignored Resident 1's demand to vacate a spot in the hallway. Staff intervened and separated the residents, and Resident 19 was placed on alert charting. Resident 19 reported no pain or injuries from the incident. Despite the intervention, the facility's records revealed that Resident 1 had a resolved care plan for physical aggression toward another resident, indicating a history of such behavior. Interviews conducted on 4/18/24 and 4/19/24 confirmed the incident, with Resident 1 admitting to having a temper and acknowledging the possibility of such behavior. Observations from 4/15/24 to 4/18/24 showed that Resident 19 and Resident 1 did not interact during this period. The facility's failure to prevent this incident placed residents at risk for abuse.
Failure to Maintain Nutritional Status for Residents
Penalty
Summary
The facility failed to maintain healthy nutritional parameters for three residents, leading to significant weight loss and inadequate nutritional intake. Resident 32, who had a history of stroke and dementia, experienced an 8% weight loss from 148 pounds to 135 pounds within a month. Despite this significant weight loss, there was no documentation of a Nutritional Assessment or discussion by the Nutrition At Risk committee. The resident's nutritional supplement was discontinued due to gastrointestinal upset, but no alternative interventions were documented or implemented to address the weight loss. Resident 60, diagnosed with severe protein-calorie malnutrition, had a documented weight loss greater than 7.5% over three months. The resident's weight fluctuated significantly, and there were multiple instances where daily weights were not documented as required. Despite physician orders to provide a nutritional supplement and obtain daily weights, there was no consistent documentation or follow-up on the resident's nutritional status. Staff acknowledged potential issues with weighing procedures and the need for staff education. Resident 358, admitted with adult failure to thrive, had inadequate meal intake and significant weight loss. The resident's meal consumption was consistently low, with many instances of consuming only 0-25% of meals. Despite orders for nutritional supplements and meal replacements, there was minimal documentation of these interventions being offered or consumed. The resident's weights were not consistently recorded, and staff confirmed that meal replacements were not regularly offered despite the resident's poor intake. The facility's policy on weight monitoring and meal replacement was not followed, leading to further nutritional decline for the resident.
Failure to Maintain Communication with Dialysis Center
Penalty
Summary
The facility failed to ensure ongoing communication with the dialysis center for a resident with chronic kidney disease who was dependent on dialysis. The resident's care plan indicated scheduled dialysis days, but there were no communication forms between the facility and the dialysis provider for a period of nearly a month. This lapse was confirmed by the LPN Unit Manager, who acknowledged the importance of the communication form, and the Director of Nursing Services, who was unable to provide the missing documentation.
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What surveyors actually found near you
We read the 22 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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 Medford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avamere At Three Fountains | 0.5 mi | ★★★★★ | 5 | 0 |
| Hearthstone Nursing & Rehabilitation Center | 2.4 mi | ★★★★★ | 6 | 0 |
| Rogue Valley Manor | 2.5 mi | ★★★★★ | 0 | 0 |
| Ashland Post Acute | 11.7 mi | ★★★★★ | 8 | 0 |
| Regency Care Of Rogue Valley | 23.6 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.