Avamere Health Services Of Rogue Valley
Inspection history, citations, penalties and survey trends for this long-term care facility in Medford, Oregon.
- Location
- 625 Stevens Street, Medford, Oregon 97504
- CMS Provider Number
- 385024
- Inspections on file
- 23
- Latest survey
- August 22, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Avamere Health Services Of Rogue Valley during CMS and state inspections, most recent first.
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.
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.
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 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.
Latest citations in Oregon
A resident with acute respiratory failure and heart failure had a documented Full Code status and a POLST specifying Attempt Resuscitation/CPR and Full Treatment. During night rounds, two CNAs found the resident not breathing, cool to the touch, with yellow skin and no pulse, but did not initiate CPR or call a code blue, instead going to notify an LPN. The LPN assessed the resident, confirmed absence of vital signs, noted the body was cold with mottling and no rigor mortis, and contacted the DNS, physician, and 911 for the coroner’s number, but did not start CPR or activate a code blue. No lifesaving measures were attempted despite facility policy requiring CPR for unresponsive residents without a valid DNR and the resident’s clearly documented full code status, leading surveyors to cite Immediate Jeopardy and substandard quality of care.
A resident with respiratory failure and pneumonia, who was Full Code and not on hospice, was found during routine rounds and suspected to be deceased. Nursing staff assessed the resident, noted there was no rigor mortis, confirmed death, and did not initiate a code blue or any resuscitation efforts despite the resident’s Full Code status. The facility later treated this as a potential neglect incident but did not report it to the State Agency within the required two-hour timeframe, as confirmed by the regional QA director.
A resident with chronic pain and a left below-knee amputation, who required supervision or touching assistance with ADLs, was discharged after returning from an outing shortly after midnight. Although discharge instructions noted the need for assistance and assistive devices, there was no documentation of referrals for medical equipment or home health services. Facility staff documented that the resident was discharged because they were out past midnight and believed Medicare would not cover the stay, did not issue a NOMNC, and recorded the discharge as voluntary despite the resident later reporting they had been “kicked out” and were sleeping on a friend’s couch with difficulty getting around. Staff interviews revealed no financial issues and indicated the resident had originally been scheduled for discharge at a later date.
A resident with a hip fracture and anxiety reported to social services that a CNA had been rough, told the resident to take themself to the bathroom, and instructed them not to get out of bed until a specified early morning time. The allegation was received by facility staff in the late afternoon, but the incident report was not submitted to the State Agency until the following day, exceeding the required 2-hour reporting timeframe acknowledged by the DNS. The deficiency concerns this untimely reporting of an abuse allegation, despite the CNA’s denial of any abuse.
A resident with hemiplegia, previously evaluated as not appropriate to self-administer any medications, was found to have open tubes of antifungal cream, anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) stored in a bedside drawer. Record review showed there were no MD orders for several of these topical products and no order permitting self-administration. An RN case manager confirmed the absence of orders, and the resident reported self-administering the medications, demonstrating a failure to ensure medications were administered only as ordered and in accordance with the resident’s assessed ability.
A resident with hemiplegia, previously evaluated as not appropriate to self-administer medications, was found with open containers of anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) in a bedside drawer. Record review showed no MD orders, no documented indication for use, and no monitoring for these medications. An RN case manager confirmed there were no orders and that staff did not administer or monitor the creams, while the resident reported self-administering them.
The facility failed to investigate multiple staff-reported allegations that one cognitively intact, wheelchair-using resident engaged in sexually inappropriate behaviors toward three other residents with significant cognitive and neurological impairments. Staff reported finding a resident with a ripped brief, crying and resisting care, and suspected sexual contact; they also reported that the alleged aggressor tried to take another resident into a shower room for sexual acts, attempted to video and kiss that resident, and encouraged a third resident to remove their top while present with a phone. CNAs, social services, and other staff stated they informed the administrator, DNS, HR, and unit management about these incidents and behaviors, but the administrator acknowledged that no investigations were conducted, despite being aware of the reports.
A resident with multiple sclerosis, care planned as dependent on two staff and requiring a Hoyer lift for transfers, was instead transferred by a CNA using a stand-pivot method without the lift or a second staff member. The CNA reported she had not read the resident’s care plan and described performing the transfer by giving the resident a “giant bear hug” and making several attempts to move the resident from chair to bed. The resident reported right flank pain and stated the transfer caused three broken ribs, although an x-ray later showed no rib fractures or dislocation and no visible injury was noted.
A resident with multiple sclerosis was admitted with physician orders for PT and OT, but review of the clinical record showed no documentation that these therapies were ever provided. The resident reported not receiving any therapy since admission, and the Director of Rehabilitation confirmed that no therapy services had been delivered during this period despite active orders, resulting in a failure to provide ordered rehabilitative services.
A dependent resident with dementia and a history of stroke, identified on the MDS as requiring staff assistance for showers, did not consistently receive scheduled bathing, and one CNA falsely documented that bathing had been provided. CNA task reports showed missed or undocumented baths on scheduled days, and an internal investigation confirmed that a bath recorded as completed on one date had not actually occurred. Staff interviews indicated that if bathing was not documented it usually did not occur, and that scheduled bathing was expected to be provided by staff.
Failure to Initiate CPR for a Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide CPR in accordance with a resident’s documented full code status. The facility’s Emergency Procedure CPR policy, initiated in 2001, required staff trained in CPR to initiate resuscitation on unresponsive residents who were not breathing unless there was a valid DNR order or clear signs of irreversible death such as rigor mortis. The policy further specified that if a resident’s DNR status was unclear, CPR should be started and continued until a DNR was confirmed. Resident 3 had been admitted with diagnoses including acute respiratory failure and heart failure and had a care plan and POLST on file indicating Full Code/Attempt Resuscitation and Full Treatment, including use of intubation, advanced airway interventions, mechanical ventilation, and transfer to hospital or ICU if indicated. On the night of the incident, a CNA (Staff 5) documented last vital signs for the resident at approximately 10:45 PM, with oxygen saturation of 92% on one liter of oxygen. At 2:00 AM, the resident was observed sleeping, breathing, and with a dry brief. Around 4:00 AM, Staff 5 and another CNA (Staff 8) entered the resident’s room and observed that the resident was not breathing, had yellow skin color, was cool to the touch, and had no palpable pulse. Both CNAs concluded the resident was deceased and went to notify the LPN (Staff 4) instead of initiating CPR or calling a code blue, despite having recent CPR training and later stating that, in retrospect, they would have started CPR and called for a code blue. When Staff 4 (LPN) entered the room, she assessed the resident and found no pulse, blood pressure, or respirations, noted the body was cold, with some mottling on the lower legs, pale/yellowish skin color, and no rigor mortis. Staff 4 did not initiate a code blue or CPR and instead contacted the DNS (Staff 2) and the physician, and then called 911 to obtain the coroner’s phone number. No lifesaving measures were attempted by any staff, despite the resident’s documented full code status and the facility policy requiring CPR in the absence of a valid DNR or signs of irreversible death. The DNS later stated she expected staff to call a code blue immediately, start CPR, call 911, and verify the resident’s code status. Surveyors determined that the facility failed to provide CPR according to the resident’s code status, placing all residents with full code status at risk and constituting substandard quality of care, with the noncompliance cited as Immediate Jeopardy and Past Noncompliance.
Removal Plan
- Administrator, DNS and nursing staff would be re-educated on the code blue process, how to locate a resident's code status in PCC and the POLST on file, and the importance of following individual resident care plans and orders.
- Resident code status would be cross-referenced with the PCC order, POLST scanned in binder, care plan, and resident dashboard.
- DNS or designee would monitor resident code status preferences for new admissions/returning admissions from hospitalizations.
- DNS or designee would audit code status for all new admissions and readmissions from hospitalization or ED visits, and share audit results with the QAPI committee to ensure substantial compliance is maintained.
- DNS or designee would complete a mock code.
- DNS or designee would complete mock codes.
Failure to Timely Report Alleged Neglect Involving Lack of CPR for Full Code Resident
Penalty
Summary
The facility failed to timely report an allegation of potential neglect related to CPR to the State Agency for one resident. The resident was admitted in February 2026 with diagnoses including respiratory failure and pneumonia and had a Full Code status, was not on hospice, and therefore was to receive CPR if found unresponsive. According to the facility’s investigation dated six days after the resident’s death, staff found the resident during routine rounds and suspected the resident was deceased, notified the nurse, and the nurse confirmed the resident was deceased. The investigation documented that at the time of the nurse’s assessment the resident did not have rigor mortis, yet the nurse did not initiate a code blue or any resuscitation interventions despite the Full Code status. The incident, which occurred on an identified date, was not reported to the State Agency until a later identified date, and the Regional Director of Quality Assurance confirmed that the facility did not report the incident within the required two-hour timeline. This failure to timely report the allegation of potential neglect involving the lack of CPR initiation for a Full Code resident constituted the deficiency identified by surveyors.
Failure to Ensure Safe and Orderly Discharge After Late Return from Outing
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and orderly discharge for a resident who was admitted with chronic pain, a left below-knee amputation, and post-surgical aftercare needs. An admission MDS completed shortly after admission documented that the resident was cognitively intact but required supervision or touching assistance with toileting, transfers, and bathing. Discharge instructions indicated the resident was being discharged home and that the resident’s current physical status required assistance and assistive devices, yet there was no documentation of referrals for needed medical equipment or a home health referral. The facility’s records did not show that these services or equipment were arranged prior to discharge. On the night in question, a nursing note documented that the resident returned to the facility after an outing at 12:23 AM, after the facility had notified the police because the resident’s location was unknown. The resident reported having been out with friends and being unaware of any concern. A social services note stated that because the resident was out past midnight, the resident was discharged from the facility, and a NOMNC was not issued because the resident left prior to the scheduled discharge and on their own initiative. A discharge summary documented that discharge instructions were reviewed with the resident, who refused to sign and was leaving voluntarily, and the voluntary consent form included a handwritten statement that the resident refused to sign. Later, the resident stated they had been “kicked out” for coming back late and were sleeping on a friend’s couch, finding it difficult to get around. Staff interviews showed there were no financial issues documented, that staff believed Medicare would not cover the resident if out past midnight, and that the resident had been scheduled for discharge several days later, while a regional director later characterized the situation as a clerical error and confirmed a normal discharge should have been completed.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to timely report an allegation of abuse to the State Agency after a resident reported that a CNA had been rough and verbally directive with them. The resident, who had been admitted with diagnoses including a hip fracture and anxiety, stated that the CNA was “kind of rough,” told the resident to take themself to the bathroom, and instructed the resident not to get out of bed until 6:00 AM. The resident reported this allegation of abuse involving the CNA to the social services staff member at 4:00 PM on 1/29/26. According to the facility’s investigation documentation, the allegation was received by staff at 4:00 PM on 1/29/26, and the Facility Reported Incident form was not received by the State Agency until 2:13 PM on 1/30/26. The DNS acknowledged that the facility became aware of the allegation at 4:00 PM on 1/29/26 and that it should have been reported to the State Agency within two hours but was not. The CNA denied abusing the resident or any resident, but the deficiency centers on the delay in reporting the allegation to the State Agency within the required timeframe.
Failure to Prevent Unauthorized Self-Administration of Non-Prescribed Medications
Penalty
Summary
Surveyors identified that a resident was self-administering non-prescribed topical medications despite a documented determination that they were not appropriate to self-administer any medications. The resident, admitted with hemiplegia, had a Self-Medication Administration Evaluation dated 11/13/25 indicating they were not appropriate to self-administer medications. During an observation on 3/19/26 at 7:50 AM with a RN case manager, open tubes of antifungal cream, anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) were found in the resident’s bedside table drawer. Review of the clinical record showed there were no physician orders for the anti-itch cream, hydrocortisone cream, or DMSO, and the resident did not have an order to self-administer any medications. The RN case manager confirmed the lack of orders for these medications, and at 8:10 AM the resident stated they did self-administer the medications found in their room. This constituted a failure by the facility to ensure the resident did not self-administer non-prescribed medications and to provide treatment and care according to physician orders and the resident’s evaluated ability to self-administer medications.
Unmonitored Self-Administration of Topical Medications Without Physician Orders
Penalty
Summary
The facility failed to ensure a resident’s drug regimen was free from unnecessary drugs by not providing adequate monitoring, indication for use, or physician orders for multiple medications. A resident admitted with hemiplegia in May 2024 had a self-medication administration evaluation dated 11/13/25 indicating they were not appropriate to self-administer any medications. During an observation on 3/19/26, an RN case manager found an open tube of anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) in the resident’s bedside table drawer. Record review showed no physician orders, no documented indication for use, and no monitoring for these medications. The RN case manager confirmed the resident did not have orders for the anti-itch cream, hydrocortisone cream, or DMSO, and that staff did not administer or monitor these medications. The resident stated they self-administered the medications found in their room, despite the prior evaluation determining they were not appropriate to self-administer any medications.
Failure to Investigate Multiple Allegations of Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to investigate multiple allegations of sexual abuse involving three residents. Resident 102, who had cognitive loss equivalent to a young child, legal blindness, and was non-verbal, was reportedly found with a ripped brief, crying, and resisting a brief change. Staff reported concerns that another resident, Resident 105, had performed or attempted to perform sexual acts on Resident 102. Staff members, including CNAs and social services, stated they informed facility management, including the Administrator and DNS, about the torn brief, Resident 102’s distress, and concerns that Resident 105 was being sexually inappropriate with multiple residents. Despite these reports and discussions in morning meetings, the Administrator acknowledged that no investigation was completed, believing the incident was based on staff assumptions. The facility also failed to investigate allegations involving Resident 103, who had Alzheimer’s disease and Parkinson’s disease. Staff reported that Resident 105 attempted to take Resident 103 into a shower room to perform sexual acts, and that a staff member intervened. The complainant later spoke with Resident 103, who stated that Resident 105 was “sick” and made bad comments. Other staff reported to human resources, the DNS, and the Administrator that Resident 105 attempted to take a resident into a shower room to unclothe the resident, and that Resident 105 attempted to video Resident 103, expressed a desire to kiss Resident 103, and get the resident into a shower room. The Social Service Director confirmed she reported these concerns to the Administrator, who stated he was aware of the incident but that no investigation was completed. A third failure to investigate involved Resident 108, who had Huntington’s disease and dementia. A staff member reported observing Resident 105 telling Resident 108 to take off their shirt and gesturing for them to do so, and stated they completed a written statement and gave it to the unit manager. Another CNA reported hearing that Resident 105 and other residents were laughing and encouraging Resident 108 to remove their top, and also reported observing Resident 105 rubbing other residents’ backs more physically than appropriate. Social services reported being told that Resident 108 was removing their top while Resident 105 was in the dining room with a phone, and that Resident 105 admitted to the behavior but described it as innocent. The Administrator stated he was aware of Resident 108 removing their shirt while Resident 105 was present, yet confirmed that no investigation was completed for this incident. These failures to investigate led surveyors to determine that the facility did not respond appropriately to alleged violations of sexual abuse for the three residents.
Removal Plan
- Residents 102, 103, and 108 received head-to-toe skin assessments completed by RCMs with no observed findings.
- Resident 105 was placed on one-to-one observations pending investigations.
- Staff 1 (Administrator) and Staff 2 (DNS) were re-educated on the facility's abuse policy, reporting, and thorough investigations.
- Social Services will interview all interviewable residents regarding abuse.
- Nurses will complete a head-to-toe assessment on all non-interviewable residents.
- All staff, including agency staff, will be re-educated on the facility's abuse policy and reporting.
Failure to Follow Care-Planned Hoyer Lift Transfer Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow a resident’s care plan interventions for transfers, resulting in a transfer being performed without required equipment and assistance. A resident admitted in February 2026 with multiple sclerosis had a 2/25/26 ADL care plan indicating the resident was dependent on two staff members for transfers and required use of a Hoyer (mechanical) lift. Despite this, on 2/28/26 a CNA (Staff 3) performed a stand-pivot transfer without the Hoyer lift and without a second staff member. The resident later reported that Staff 3 gave a “giant bear hug” and made several attempts to transfer the resident from chair to bed, after which the resident reported right flank pain and stated the transfer caused three broken ribs. An x-ray on 3/10/26 showed no rib fractures or dislocation, and the resident was assessed to have no visible injury. During interview, Staff 3 confirmed she had completed a stand-pivot transfer with the resident and acknowledged she had not read the resident’s care plan, and the Administrator confirmed that the resident had been care planned for a two-person Hoyer lift transfer at the time of the incident.
Failure to Provide Ordered Rehabilitative Services
Penalty
Summary
The facility failed to provide ordered rehabilitative services to a resident with multiple sclerosis. The resident was admitted in February 2026 with admission orders dated 2/24/26 for both physical therapy and occupational therapy. Review of the resident’s clinical record showed no documented evidence that any therapy services were provided as ordered. In an interview on 3/11/26 at 10:58 AM, the resident reported not having received any therapy since admission. During a separate interview on 3/11/26 at 10:40 AM, the Director of Rehabilitation confirmed that the resident had not received any therapy services from the date of admission through 3/11/26, despite the existing orders for physical and occupational therapy. This failure to implement the physician’s orders for rehabilitative services for this resident placed the resident at risk for a decline in range of motion.
Failure to Provide and Accurately Document Scheduled Bathing for a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a dependent resident received required assistance with activities of daily living (ADLs), specifically bathing, and inaccurate documentation that bathing had been provided. The resident, admitted in 10/2025 with dementia and stroke, had a 10/21/25 admission MDS indicating severe cognitive impairment and dependence on staff for showers. The facility’s 12/2025 CNA task report showed the resident was scheduled for bathing on day shift on Wednesdays and Sundays. On 12/24/25, the task report was blank for bathing, and on 12/28/25, the report documented that the resident received bathing and was dependent on staff for assistance. However, a 12/29/25 facility investigation determined the resident did not receive a bath on 12/28/25 and that it had been falsely documented that bathing occurred. A Facility Reported Incident form dated 12/31/25 further documented that on 12/28/25, a CNA (Staff 5) noted providing bathing to the resident but did not provide any type of bathing. Additional record review showed that the resident’s 3/2026 CNA task report contained no documentation that any type of bathing was provided on 3/11/26. Attempts to contact Staff 5 on 3/16/26 and 3/17/26 were unsuccessful. During interviews, another CNA (Staff 7) stated that on 12/28/25 she observed Staff 5 lay the resident down and, when she asked about bathing, Staff 5 said she would complete the resident’s bathing in the evening; Staff 7 stated she could not perform the resident’s bathing in the evening because she moved to a different hall on evening shift. Another CNA (Staff 21) stated that usually if bathing was not documented in the resident’s record, bathing did not occur. The Regional Nurse (Staff 31) stated that staff should provide scheduled bathing to residents.
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