Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avamere Riverpark Of Eugene during CMS and state inspections, most recent first.
Narcotic drug records were not kept in order and a count of controlled drugs was not maintained for 6 of 6 med carts reviewed. Review of the North, South, and Central Hall narcotic logbooks showed multiple missed opportunities where staff did not verify the narcotic count was correct, despite policy requiring two staff members to count narcotics after every shift and sign the narcotic logbook together.
Failure to honor a resident’s diet choice: A cognitively intact resident with chronic respiratory failure was on a minced and moist diet with many pureed foods and repeatedly asked for an SLP re-eval because the resident refused the pureed items and wanted a diet without them. The record showed the request was raised at care conferences and the resident reported not liking the diet and having poor appetite, while the annual MDS noted declined weight and mid-arm circumference checks and risk for weight loss, muscle loss, weakness, and delayed wound healing. The SLP had not re-evaluated swallowing, and neither the RCM/LPN nor the SLP had completed a Risk/Benefit Assessment.
A resident with ALS developed a swallowing decline, was made NPO, refused an NG tube, and lost significant weight over a short period. Although later MDS documentation reflected swallowing issues and significant weight loss, the record showed no Significant Change MDS was completed. Staff confirmed the resident had a change in swallowing ability and significant weight loss and acknowledged the Significant Change MDS should have been completed.
Failure to Provide Oral Hygiene Assistance: A cognitively intact resident with epilepsy had a care plan for reminders and setup with oral care, but staff did not provide the expected twice-daily oral hygiene assistance. The resident reported repeated refusals when asking for help, had not received brushing assistance for an extended period, and no toothbrush could be located in the room despite toothpaste being present.
Failure to provide grooming and oral hygiene assistance for two residents. One cognitively intact resident with chronic respiratory failure had matted, unbrushed hair and stated staff did not brush the hair daily, while multiple CNAs said they never brushed it during care. Another resident with DM and neuropathy stated staff did not assist with oral care despite requests; toothbrush and toothpaste were hidden in a closet bin among other items, and a CNA said he had not assisted with tooth brushing during the shift.
Failure to Follow Orders for Meds, Weights, and Labs: A resident with type 2 DM received hydrocodone-acetaminophen three times in one day, but only two doses were documented in the MAR, while an LPN and a CMA stated one dose each was not entered. Another resident with HF and a stroke had ordered daily weights and provider notification parameters, but weight gains meeting the order were not reported. A third resident with a stroke and alcoholic cirrhosis had weekly BMP labs ordered, but the labs were repeatedly not completed because the LPN had not been trained to obtain blood samples.
A resident with urinary retention and a history of recurrent UTIs was scheduled for a urology visit, but the appointment was missed and not rescheduled. The resident later had multiple UTI diagnoses, and the DNS confirmed the missed specialist visit was intended to help manage the recurring UTIs.
A resident with heart failure and arterial fibrillation received metoprolol succinate even when the resident’s HR was below the ordered hold parameter of 60 bpm. An LPN and an RN acknowledged administering the medication despite low HR readings, and the RCM stated staff were expected to hold the dose when the HR was under 60 bpm.
Improper insulin storage was observed on a medication cart when one resident's insulin had been removed from the refrigerator and was not dated, and another resident's unopened insulin was left on the cart instead of being refrigerated. An LPN confirmed the storage errors, and the RDC stated nursing staff are expected to follow proper medication storage requirements, including refrigeration and dating of insulin.
Inaccurate oral hygiene documentation was found for a resident with DM and diabetic neuropathy who said staff did not assist with brushing teeth despite requests and that oral hygiene supplies were not available in the room. Task records showed oral care was completed by CNAs, but both CNAs stated they did not provide the documented care, and the DNS confirmed it was not acceptable to document care that was not done.
The facility failed to provide written notice to a cognitively intact resident about why a service dog could not remain in the room and failed to obtain evaluation or consent for another resident's Wander Guard, which was used because of elopement risk. The records showed one resident with Parkinson's disease, anxiety, and panic disorder was told verbally that the dog could not stay, while another resident with brain cancer and personality disorder had a Wander Guard in place without documented consent or evaluation.
Failure to accurately assess and supervise two residents with elopement risk led to one resident being found outside near a busy intersection in a confused, cold, and inadequately clothed state, while another resident with severe cognitive impairment exited the building after entering the door security code. Staff reported repeated exit-seeking and agitation, but a revised elopement risk evaluation was not completed and care plan supervision was not consistently followed.
Delayed response to resident call lights occurred for two residents. One resident with ALS had multiple call lights lasting over 30 minutes, including a restroom request that took nearly 40 minutes and an observed call light that remained on for more than 30 minutes while staff were busy and the resident needed 2-person assistance. Another resident with TBI and chronic pain had repeated long waits for help, including during smoke breaks and after a bed-soaking incident, with staff reporting communication failures and delayed call light response.
A resident with a history of stroke sustained rib fractures and a closed head injury after a shower chair, previously identified as broken and not properly inspected or removed from service, collapsed during use. Facility records showed that required equipment inspections were not completed, and staff failed to communicate or address the chair's unsafe condition before it was used again.
Two residents did not receive proper incontinence and catheter care as required by their care plans and physician orders. One resident was repeatedly found with dried feces on their body and reported not receiving timely care unless they specifically requested it. Another resident with a catheter was not changed or checked for an extended period during a night shift, despite clear orders for care each shift. Staff interviews confirmed lapses in care and delays in responding to resident needs.
A resident with diabetes experienced a breach of dignity when a nurse performed a blood sugar check and administered insulin in a public dining area without consent. Despite the resident's request for the injection to be given in the arm, the nurse lifted the resident's shirt and injected the insulin into the abdomen, an action acknowledged by two resident care managers as undignified.
A facility failed to include a resident's representative in the care planning process for a resident with stroke and aphasia. Despite the resident's communication challenges, the family member, who was the main contact, did not receive invitations to care conferences due to outdated address information. The facility had not attempted to contact the family member for nine months, and the Social Services Coordinator acknowledged the lack of communication to ensure family involvement.
The facility failed to notify residents, their representatives, and the ombudsman of hospital transfers for three residents, including those with cellulitis, heart failure, seizures, gastroenteritis, and colitis. The lack of transfer notices was confirmed by facility staff.
The facility failed to provide written notice of its bed hold policy to residents or their representatives during hospital transfers, affecting three residents. One resident with cellulitis and heart failure, another with seizures, and a third with gastroenteritis were transferred without receiving the necessary information. Staff members admitted to not understanding the process and lacking training, which was acknowledged by the facility's administration.
The facility failed to provide meaningful activities for two residents, one with a stroke and severely impaired cognition, and another with depression. Despite documented interests and care plans, there was no record of participation in activities for the past month. Observations showed one resident frequently in bed with a muted TV, while the other reported not receiving in-room activities. Staff interviews revealed a lack of awareness and facilitation of activities, leading to a diminished quality of life.
Two residents experienced inadequate assessment and documentation of pressure ulcers. One resident had inaccurately documented sacral ulcers, while observations showed ulcers on the buttocks. Another resident's knee wound, caused by an ill-fitting prosthetic, was misclassified as an abrasion instead of a pressure wound. Staff acknowledged inaccuracies in both cases.
The facility failed to ensure that two cognitively intact residents understood the arbitration agreements they signed. One resident, admitted with muscle weakness, and another with a pressure ulcer, were unaware of signing the agreements, and no explanation was provided. The administrator acknowledged the oversight.
A resident with chronic respiratory conditions was prescribed an antibiotic for an upper respiratory infection without confirming the diagnosis through appropriate diagnostic tests. The facility's Infection Preventionist admitted that the resident did not meet the McGeer's Criteria for antibiotic use, which is used for antibiotic stewardship, leading to a deficiency in care.
The facility failed to notify physicians of condition changes for three residents, including refusals of treatment and medication administration errors. One resident with kidney failure refused daily weights and blood sugar checks without physician notification. Another resident with a stroke was lethargic after medications were crushed and administered improperly, leading to hospitalization. A third resident with cellulitis and heart failure experienced uncontrolled pain and drainage, but the physician was not informed.
The facility did not update care plans for two residents with changing conditions, leading to potential unmet needs. One resident with recurrent UTIs had an outdated care plan, while another with heart failure and severe obesity did not receive personalized care for hygiene and edema. Staff acknowledged the care plans were not revised to reflect the residents' ongoing and increased care needs.
The facility failed to follow professional standards for medication administration and equipment sanitization. A resident with bipolar disorder was hospitalized after an RN crushed and administered lithium ER, contrary to guidelines, leading to elevated lithium levels. Another resident's glucometer was improperly sanitized, indicating a lack of adherence to infection control practices.
A resident with swallowing difficulties was not properly supervised while eating, as required by their care plan. Staff left the resident unattended in the dining room, leading to a risk of aspiration or choking. Interviews confirmed that close supervision was not provided, as staff were not within arm's length or at the same table as the resident.
The facility failed to adequately assess and monitor the respiratory status of two residents, leading to deficiencies in care. One resident with chronic respiratory conditions did not receive thorough assessments despite ongoing symptoms, while another resident's CPAP machine was not regularly cleaned as required. Staff acknowledged these oversights, which were not documented in nursing notes.
The facility failed to provide adequate staffing, resulting in delayed care for two residents. One resident with severe obesity and diabetes experienced long waits for toileting assistance, while another with quadriplegia had a call light out of reach, delaying care. Staff reported understaffing, especially on weekends, and the DNS's expectations for call light response times were not met.
A resident with bipolar disorder was hospitalized after a nurse crushed and administered lithium ER in pudding, despite instructions not to crush the medication. This resulted in altered mental status and elevated lithium levels, requiring ICU transfer. The error was acknowledged by the RN and DNS, but no documentation was found in the electronic record.
A facility failed to properly sanitize a community use glucometer between resident uses, placing residents at risk for bloodborne illness. An RN was observed using alcohol prep wipes to clean the glucometer after checking a resident's CBG level, unaware of the proper sanitizing wipes required. Two LPNs later confirmed the correct procedure was not followed.
The facility failed to follow physician orders and care plans for three residents, leading to unmet care needs. One resident did not receive prescribed Morphine on two occasions, another was left unattended in a bathtub and became unresponsive, and a third did not receive prescribed colchicine for 12 days due to pharmacy issues.
Narcotic Count Records Not Verified After Shifts
Penalty
Summary
The facility failed to ensure narcotic drug records were in order and that a count of all controlled drugs was maintained for 6 of 6 medication carts reviewed for medication administration. The 1/2023 Ordering and Receiving Controlled Medications policy stated that the pharmacy or nursing care center prepares an individual resident-controlled substance log for each controlled substance medication prescribed for a resident, and that the log is placed in the Narcotic book to be counted after every shift. Review of the North Hall, South Hall, and Central Hall narcotic logbooks showed multiple instances on 1/31/26 and 2/24/26 where facility staff did not verify the narcotic count was correct during counting opportunities. On 2/25/26 at 1:10 PM, Staff 2, the DNS, acknowledged that two staff members were to count the narcotics after every shift and sign the narcotic logbook together verifying the narcotic count was correct.
Failure to Honor Resident Diet Choice
Penalty
Summary
The facility failed to facilitate a resident’s right to make choices about diet for 1 of 4 residents reviewed for choices. Resident 5 was admitted in 2023 with a diagnosis of chronic respiratory failure and had a 12/2025 BIMS assessment showing the resident was cognitively intact. The resident stated on 2/23/26 that multiple requests had been made to be re-evaluated by speech therapy because the resident had been prescribed a minced and moist diet that included many pureed foods, which the resident refused to eat and wanted changed to a diet with no pureed foods. The resident also stated waiting several months for the re-evaluation. The clinical record showed the resident requested a diet re-evaluation at care conferences in 7/2025 and 1/2026. A progress note from 7/30/25 documented the resident reported not liking the current diet, and the annual MDS completed in 10/2025 showed the resident had declined weight and mid-arm circumference checks and was at risk for weight loss, muscle loss, weakness, and delayed wound healing. A 11/25/25 progress note documented poor appetite due to disliking the food. On 2/27/26, the SLP stated she had not re-evaluated the resident’s swallowing and had not completed a Risk/Benefit Assessment. The RCM/LPN stated she had not completed a Risk/Benefit Assessment related to the diet, and the DNS stated that when a resident wants something medically contraindicated, staff should try to reach a mutually agreeable solution and complete a Risk/Benefit Assessment with the resident.
Failure to Complete Significant Change MDS After Swallowing Decline and Weight Loss
Penalty
Summary
The facility failed to conduct a Significant Change MDS assessment for Resident 47, who was admitted with a diagnosis of Amyotrophic Lateral Sclerosis. A quarterly MDS in 10/2025 indicated the resident did not have swallowing issues and did not have significant weight loss, but a 12/19/25 progress note documented that the resident was not safe to swallow and was recommended to be NPO with an NG tube for alternate nutrition. On 1/12/26, the record noted the resident had been NPO since 12/19/25, including food and medications, had refused an NG tube, and had lost 20 pounds since 10/2025. Weight records showed a decline from 140.6 pounds on 10/7/25 to 121 pounds on 1/7/26. A 1/20/26 quarterly MDS later documented swallowing issues and significant weight loss, and a 2/13/26 progress note indicated an NG tube was placed and tube feeding was started. Review of the medical record showed no indication that a Significant Change MDS had been completed. Staff interviews confirmed that a Significant Change MDS is expected when a resident has a decline in two or more areas that does not resolve in two weeks, and the DNS acknowledged the resident had a change in swallowing ability in 12/2025 and significant weight loss in 1/2026, stating the resident should have had a Significant Change MDS completed in 1/2026.
Failure to Provide Oral Hygiene Assistance
Penalty
Summary
The facility failed to provide care and services to maintain oral hygiene for 1 of 5 sampled residents reviewed for ADLs. Resident 3 was admitted with diagnoses including epilepsy and had a care plan dated 8/6/25 indicating a need for reminders and set up for oral care. A 2/11/26 quarterly MDS showed the resident required setup or cleanup assistance for oral hygiene and had a BIMS score of 15, indicating cognitive intactness. During interviews and observations, Resident 3 stated staff were directed to help brush his/her teeth twice a day but did not do so, and the resident said he/she no longer requested oral hygiene assistance because staff frequently said no. On 2/24/26, the resident estimated the last time help with brushing teeth was in 1/2026 and stated he/she did not know where a toothbrush was because it had not been used recently. The resident’s overbed table, nightstand, restroom, and in-room sink were searched and no toothbrush was found, although an oral care basin with toothpaste was observed on the nightstand. On 2/25/26, the resident again reported oral hygiene had not occurred and still did not have a toothbrush. Staff 27 later reported he had not yet assisted the resident with oral hygiene that day and could not locate a toothbrush in the room or bathroom, and Staff 2 confirmed the expectation was for staff to offer oral hygiene opportunities at least twice a day and that Resident 3 was not provided oral hygiene as expected.
Failure to Provide Grooming and Oral Hygiene Assistance
Penalty
Summary
The facility failed to provide care and services to maintain grooming and oral hygiene for 2 residents reviewed for ADLs. One resident, admitted with chronic respiratory failure and documented as cognitively intact on the annual MDS, had a care plan indicating staff assistance was needed for personal hygiene. The resident was observed with unbrushed, matted hair, and stated that staff did not brush the hair daily and that knots on the back of the head could not be brushed out independently. Multiple CNAs stated they had cared for the resident and did not brush the hair, and the DNS stated staff were expected to offer to brush residents’ hair daily. A second resident, admitted with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, had a care plan calling for reminders and setup assistance with oral care, and a quarterly MDS showing setup or cleanup assistance for oral hygiene with intact cognition. The resident stated staff did not assist with oral hygiene despite requests and said total assistance was needed for tooth brushing. Oral hygiene supplies were not visible in the room; a dry toothbrush and facility-issued toothpaste were found at the bottom of a large plastic bin on a closet shelf, buried among other personal items and an unopened box of toothpaste. A CNA stated he had not assisted the resident with brushing teeth during the shift and could not locate the supplies, and the DNS stated staff were expected to offer oral hygiene opportunities at least twice a day.
Failure to Follow Medication, Weight Monitoring, and Lab Orders
Penalty
Summary
The facility failed to follow physician orders for Resident 57, Resident 10, and Resident 11. Resident 57, admitted with type 2 diabetes mellitus, had an order for hydrocodone-acetaminophen up to twice daily as needed for pain. On 2/20/26, the MAR showed two doses documented, while the narcotic administration log showed three administrations that day. Staff 39 stated she gave a dose at 10:49 PM and was able to enter it in the MAR, not realizing two doses had already been administered that day. Staff 38 stated he gave hydrocodone-acetaminophen at 2:49 PM and again around 8:30 PM, but did not enter the second dose in the MAR. The DNS stated staff were expected to enter medications into the MAR immediately when administered. Resident 10, admitted with heart failure and a stroke, had orders for daily weights and to notify the provider if weight increased by 2 to 3 pounds over two days or 5 pounds in one week. The record showed weight increases of 3.6 pounds from 2/7/26 to 2/9/26 and 4.6 pounds from 2/13/26 to 2/14/26, with no evidence the provider was notified. Resident 11, admitted with a stroke and alcoholic cirrhosis, had an order for weekly basic metabolic panel labs. The MAR showed the labs were charted as not completed on 2/2/26, 2/9/26, and 2/16/26. Staff stated the labs were not completed because the LPN had not been trained on obtaining blood samples, and the DNS stated labs were expected to be completed as ordered.
Failure to Follow Through on Urology Care for Resident With Recurrent UTIs
Penalty
Summary
The facility failed to provide care and services to prevent a UTI for one resident with urinary retention and a history of recurrent UTIs. The resident was admitted with diagnoses including urinary retention, and a family member stated the resident had four or more UTIs in the past year. A progress note indicated the resident needed an appointment with a urologist specializing in urinary retention. The social services director scheduled the urology appointment and arranged transportation, but the clinical record contained no documented evidence that the resident was seen by the urologist as planned, and the appointment was missed. The resident was later diagnosed with UTIs on three separate occasions, and the DNS confirmed the missed appointment was not rescheduled.
Unnecessary Medication Administration
Penalty
Summary
The facility failed to ensure that one resident’s drug regimen was free from unnecessary drugs when Resident 4 received metoprolol succinate despite having a documented order to hold the medication if the heart rate was less than 60 beats per minute. Resident 4 was admitted with diagnoses including heart failure and arterial fibrillation. Record review showed that metoprolol succinate was administered on multiple occasions when the resident’s heart rate was below the ordered parameter, including heart rates of 59, 52, 56, and 58 beats per minute. During interviews, an LPN acknowledged administering the medication on several of those dates despite the low heart rates, and an RN stated she administered it when the heart rate was 59. The Resident Care Manager stated staff were expected to hold the medication when the heart rate was less than 60 beats per minute per the order.
Improper Insulin Storage on Medication Cart
Penalty
Summary
The facility failed to ensure medications were stored properly for 1 of 3 medication carts reviewed. On 2/25/26, observation of the South Hall medication cart showed Resident 15's insulin had been removed from the refrigerator and was not dated. An LPN confirmed the insulin should have been dated after it was removed from the refrigerator. The same observation found Resident 6's insulin, dated 2/18/26, unopened on the medication cart, and the LPN confirmed it should have remained refrigerated until used. Later that day, the Regional Director of Clinical stated all nursing staff are expected to follow proper medication storage requirements, including refrigeration and dating of insulin.
Inaccurate Oral Hygiene Documentation
Penalty
Summary
The facility failed to ensure resident records were complete and accurate for 1 of 5 sampled residents reviewed for ADLs, involving Resident 57, who was admitted in 6/2025 with diagnoses including type two diabetes mellitus with diabetic neuropathy. Resident 57 stated on 2/23/26 and 2/24/26 that staff did not assist with oral hygiene despite requests, and on 2/24/26 said total assistance was needed to brush teeth and that the resident did not know where oral hygiene supplies were located and had never seen a toothbrush in the room. On 2/27/26, Resident 57 reported receiving help with brushing teeth only once that week on day shift on 2/25/26 and was not offered additional opportunities for oral hygiene. However, the 2/24/26 Task: GG-Oral Hygiene report documented oral hygiene as completed by Staff 25 during the day shift, and Staff 25 later stated she did not complete oral hygiene with Resident 57 on 2/24/26. The 2/26/26 Task: GG-Oral Hygiene report documented Staff 26 assisting with oral hygiene during the evening shift, but Staff 26 stated he did not assist Resident 57 with brushing teeth that week. The DNS confirmed it was not acceptable for staff to document completion of care if it was not done.
Failure to Provide Written Notice and Consent for Service Animal Denial and Wander Guard Use
Penalty
Summary
The facility failed to ensure that a resident was informed in writing of the risks and benefits related to a restraint and that another resident received written notification regarding denial of a service dog. One resident was admitted with Parkinson's disease, anxiety, and panic disorder, had a BIMS score of 15, and was documented as requesting frequent medication because of anxiety without her/his dog. The record showed the resident's animals were very important, and the facility documented that the resident was not safe to care for the service animal in the facility, with an attendant required during visits. However, the complainant, admissions staff, and the administrator all confirmed there was no written communication provided to the resident about why the service animal was not allowed to remain in the facility. Another resident was admitted with brain cancer and personality disorder, had a BIMS score of 6, was identified as a moderate elopement risk, and used a Wander Guard daily with orders to verify placement each shift. The clinical record contained no evaluation or consent for the Wander Guard. The DNS stated the device was attached because the resident was at risk for exiting the building and confirmed the resident was able to consent but was not evaluated or given the option to consent to the Wander Guard. The regional director of clinical acknowledged the Wander Guard was a potential restraint and required an evaluation and consent for use.
Failure to assess and supervise residents with elopement risk
Penalty
Summary
The facility failed to accurately assess residents and follow elopement-related care plan interventions for two residents who were identified as at risk for exiting the building. One resident was admitted with diagnoses including a non-displaced type II dens fracture, metabolic encephalopathy, and delirium due to medical condition. After admission, staff documented fluctuating cognition, confusion, agitation, and repeated attempts to exit the facility, but the resident was not reassessed for elopement risk after staff became aware of these behaviors. On 1/17/26, the resident was found outside in the road near a busy intersection, crying, freezing cold, and not wearing a coat, jacket, or shoes, and staff reported the resident had been outside unsupervised for an estimated 20 minutes. The second resident was admitted with diagnoses including brain cancer and personality disorder. The facility’s elopement risk evaluation identified the resident as a moderate risk, and the care plan included frequent checks, use of a wheelchair, encouragement to attend activities, and evaluation of needs if the resident appeared to seek the exit. The admission MDS indicated the resident used a Wander Guard daily and had a BIMS score of 6, indicating severe cognitive impairment. Despite this, staff reported increased agitation and smoking-related exit-seeking, and a revised elopement risk evaluation was not completed even though staff acknowledged it was warranted. The resident later eloped after entering the door security code and exiting the building while supervision was not maintained. Staff reported the resident required close supervision and repeatedly attempted to get out the door, with multiple staff stating the resident had used the security code to go outside on prior occasions. Staff also stated they were not informed the resident was an elopement risk, and the investigation was not thoroughly verified to determine who last saw the resident and what occurred before the elopement.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to address call lights in a timely manner for two residents, including a resident with ALS and another resident with a history of traumatic brain injury and chronic pain. For the resident with ALS, call light audits showed multiple call lights lasting more than 30 minutes, including waits of 35 minutes, 41 minutes, 1 hour and 5 minutes, and 1 hour and 12 minutes. A grievance form documented one request for restroom assistance at 9:36 PM that was not answered until 10:15 PM, and the conclusion stated the resident waited because staff were not available due to multiple call lights and the resident was in the front lobby where staff were not aware of the resident's location. During observation, the resident's call light was seen on for more than 30 minutes before a CNA answered it, and the CNA stated the resident needed two staff members and everyone was busy. For the resident with traumatic brain injury and chronic pain, call data showed call lights answered after 30 minutes and 25 minutes on separate occasions. Grievance forms and interviews documented that the resident's call light was not answered timely after the resident soaked the bed with water and needed assistance, and that long call lights occurred during resident smoke breaks. The resident stated the call light was often delayed when toilet assistance was needed and that pain was present by the time help arrived. Staff reported that one CNA went on break and left the call light for another CNA, that another CNA did not want to answer the resident's call light during a smoke break, and that communication between staff did not occur to answer the resident's call light timely. The DNS stated the root cause of the long call lights for this resident was not addressed.
Resident Injured After Use of Uninspected Broken Shower Chair
Penalty
Summary
A deficiency occurred when a resident with a history of stroke was injured after a fall from a broken shower chair. The incident took place while a CNA was providing a shower, and the chair collapsed, resulting in the resident sustaining rib fractures, a closed head injury, and a bruise. Prior to the incident, the shower chair had previously come apart during use, and two CNAs had reassembled it. The chair was then placed in the maintenance room, but no work order or clear communication regarding its condition was made. A review of facility records showed that required monthly inspections of shower chairs were not completed in 2024 or 2025. The maintenance lead found the chair in the boiler room without any note or work order and did not take further action. The same chair was later returned to use without proper inspection or repair, leading to the resident's fall and injuries. Staff interviews confirmed lapses in the process for identifying and removing unsafe equipment from service.
Failure to Provide Adequate Incontinence and Catheter Care
Penalty
Summary
The facility failed to provide adequate incontinence and catheter care for two residents. One resident, admitted with a history of stroke and urgency incontinence, was identified as a candidate for scheduled toileting and was cognitively intact. Despite care plan interventions for scheduled toileting and peri care after incontinence episodes, there were multiple instances where the resident was found with dried feces on the body, including the groin, buttocks, and thighs. Staff interviews confirmed that the resident was not fully cleaned after incontinence episodes, and at times, the resident remained in a wheelchair all day without care unless they specifically requested assistance. Staff also reported challenges in cleaning the resident completely, with some instances of refusal, which were communicated to nursing staff as per protocol. Another resident, admitted with chronic venous hypertension and a catheter, had physician orders and care plans directing catheter care each shift. On one occasion, the resident was not provided with incontinence or catheter care during the night shift, resulting in the resident not being changed for nine hours and the catheter bag not being checked. Staff confirmed that the resident's call for assistance was not answered in a timely manner, and care was only provided on the following shift. The administrator acknowledged that the expected care was not provided as required.
Failure to Maintain Resident Dignity During Medication Administration
Penalty
Summary
The facility failed to ensure the dignity of a resident during medication administration. A resident, admitted with a diagnosis of diabetes, was subjected to a blood sugar measurement and insulin injection in a public dining area without their permission. The resident expressed a preference for the insulin to be administered in their arm, but the staff member proceeded to lift the resident's shirt and inject the insulin into the abdomen in front of other residents. This action was acknowledged by two resident care managers as a failure to protect the resident's dignity.
Failure to Include Resident's Representative in Care Planning
Penalty
Summary
The facility failed to ensure the inclusion of a resident's representative in the care planning process for a resident with a history of stroke and aphasia, who was rarely understood and used nonverbal communication. The resident was admitted in December 2023, and subsequent care plan reviews in April and July 2024 indicated that the attendance of the responsible party was marked as not applicable. Despite the resident's communication challenges, the facility did not ensure that the main contact, a family member, was invited to care conferences. The family member, who visited the facility weekly, reported not receiving invitations to these conferences. It was revealed that invitations were sent to an outdated address and returned to the facility, with the last attempt to contact the family member occurring nine months prior. The Social Services Coordinator acknowledged the lack of communication with the resident or the family member to ensure their involvement in the care planning process.
Failure to Notify Required Parties of Hospital Transfers
Penalty
Summary
The facility failed to provide timely notification to residents, their representatives, and the Office of the State Long-Term Care Ombudsman regarding hospital transfers for three residents. Resident 42, admitted with cellulitis and heart failure, was transported to the emergency department due to uncontrolled pain. Despite the completion of a discharge assessment anticipating the resident's return, no transfer notice was provided to the resident, their representative, or the ombudsman. This oversight was acknowledged by the Director of Nursing Services. Similarly, Resident 44, who had a history of seizures, was transported to the hospital without any evidence of a transfer notice being provided to the resident, their representative, or the ombudsman. The facility administrator confirmed the lack of notification. Additionally, Resident 89, admitted with non-infective gastroenteritis and colitis, was discharged to the hospital without a written transfer notice or notification to the ombudsman. The administrator acknowledged this failure as well.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notice of its bed hold policy to residents or their representatives at the time of transfer to a hospital, affecting three residents. Resident 42, admitted with cellulitis and heart failure, was transferred to the emergency department due to uncontrolled pain. There was no documentation that Resident 42 or their representative received information about the bed hold policy. Staff 14, an LPN, admitted to not understanding the process and lacking training on providing bed hold information, which was acknowledged by Staff 2, the Director of Nursing Services. Resident 44, admitted with seizures, was also transferred to the hospital without receiving the bed hold policy. The facility administrator confirmed that neither the resident nor their representative was provided with this information. Similarly, Resident 89, with a diagnosis of noninfective gastroenteritis and colitis, was discharged to the hospital without evidence of a transfer notice or notification to the State Long-Term Care Ombudsman. Staff 27, the Guest Services Coordinator, was unable to contact Resident 89 and documented a late entry.
Failure to Provide Meaningful Activities for Residents
Penalty
Summary
The facility failed to provide meaningful activities to two residents, leading to a diminished quality of life. Resident 37, who was admitted with a diagnosis of stroke and had severely impaired cognition, had a care plan that included interests in gospel music, Christmas, and bible study. Despite these documented interests, there was no record of Resident 37 participating in group or one-on-one activities for the past thirty days. Observations showed Resident 37 frequently lying in bed with the television on but muted. Staff interviews revealed a lack of awareness and assistance in facilitating Resident 37's participation in activities, despite the care plan's directives. Similarly, Resident 21, admitted with a diagnosis of depression, expressed disinterest in group activities and reported not receiving in-room activities. The medical record indicated only one instance of one-on-one activity in the last thirty days. Staff interviews confirmed that Resident 21 preferred staying in bed and that in-room activities were supposed to include electronics, television, music, and one-to-one visits. However, documentation of these activities was lacking, indicating a failure to engage Resident 21 in meaningful activities as per their preferences.
Inadequate Assessment and Documentation of Pressure Ulcers
Penalty
Summary
The facility failed to properly assess and document pressure ulcers for two residents, leading to inaccuracies in their medical records. Resident 13, admitted with muscle weakness, was identified as at risk for pressure ulcers due to incontinence and decreased mobility. Despite a care plan noting skin concerns, an incident report on 9/24/24 mentioned redness and blisters without specifying their location. Subsequent wound evaluations inaccurately documented a sacral ulcer, while observations on 10/9/24 revealed pressure ulcers on the bilateral buttocks. Staff acknowledged the investigation into Resident 13's pressure ulcers was neither accurate nor thorough. Resident 62, with a left below-knee amputation, developed a wound on the left knee initially described as an abrasion from a prosthetic leg. However, the resident and staff later identified it as a pressure wound due to friction from the ill-fitting prosthetic, exacerbated by weight loss. Despite adjustments and added padding to the prosthetic, the wound was misclassified, and staff acknowledged it met the definition of a pressure wound. This misclassification and inadequate assessment contributed to the deficiency in care.
Failure to Ensure Understanding of Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents understood the meaning of an arbitration agreement, which involves resolving disputes with a neutral party rather than in court. This deficiency was identified for two residents who were cognitively intact at the time of signing. Resident 13, admitted with a diagnosis of muscle weakness, was not aware of signing the arbitration agreement, and their family member did not recall any discussion about it. Similarly, Resident 76, admitted with a pressure ulcer, did not remember signing the agreement, and it was not explained to them. The facility's administrator acknowledged the need to ensure residents or their representatives understood the arbitration agreement.
Antibiotic Use Without Indication
Penalty
Summary
The facility failed to ensure that an antibiotic was indicated for use in a resident who was reviewed for respiratory care. The resident, admitted in July 2023, had multiple diagnoses including chronic obstructive pulmonary disease, congestive heart failure, and pulmonary hypertension. On September 22, 2024, the resident exhibited symptoms of a wet productive cough and generalized body aches but tested negative for COVID-19. Despite these symptoms, a new antibiotic order was received on September 24, 2024, for an upper respiratory infection without further diagnostic testing to confirm the infection or rule out complications from the resident's existing respiratory conditions. The Infection Preventionist acknowledged that the resident did not meet the McGeer's Criteria for an upper respiratory infection, which the facility used for antibiotic stewardship. The resident was started on an antibiotic without a chest x-ray or other lab tests to confirm the diagnosis. This oversight placed residents at risk for antibiotic-resistant organisms, as the facility did not adhere to its established criteria for antibiotic use, leading to the deficiency noted in the report.
Failure to Notify Physicians of Resident Condition Changes
Penalty
Summary
The facility failed to notify physicians regarding refusals and changes in condition for three residents, which placed them at risk for lack of physician involvement. Resident 26, admitted with kidney failure, had physician orders for daily weights and blood sugar checks, with specific instructions to notify the physician of certain changes. However, from late September to early October, the resident refused these checks, and there was no documentation that the physician was informed of these refusals. Staff confirmed that the physician was not notified during this period. Resident 442, admitted with a stroke, had a change in condition when medications were crushed and administered inappropriately, leading to lethargy and hospitalization with elevated lithium levels. Despite being notified of the resident's lethargy, staff did not assess the resident or notify the physician. Similarly, Resident 42, with cellulitis and heart failure, experienced changes in condition on two occasions, including uncontrolled pain and drainage, but there was no indication that the physician was notified. Staff acknowledged the lack of physician notification in these instances.
Failure to Update Care Plans for Residents with Changing Conditions
Penalty
Summary
The facility failed to complete and update comprehensive care plans within the required timelines for two residents, leading to potential unmet needs. Resident 38, admitted in August 2022 with kidney disease and recurrent UTIs, reported chronic bladder discomfort and urinary urgency. Despite being diagnosed with six UTIs in 2023, the care plan initiated on July 21, 2023, was not revised to address these recurring issues. Staff confirmed that the care plan interventions had not been updated since its initiation, failing to reflect the resident's ongoing condition. Resident 42, admitted in June 2024 with heart failure and severe obesity, required substantial assistance with toileting hygiene and monitoring for heart failure signs, including edema. The care plan revised on October 3, 2024, did not adequately address the resident's personal hygiene needs or the increased care needs following a September 2024 hospitalization. The resident expressed that staff often left without offering necessary assistance, and the care plan was not personalized to meet the resident's specific needs, as acknowledged by the DNS and Administrator.
Medication Administration and Equipment Sanitization Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of medication administration for two residents, resulting in significant health issues for one. Resident 442, diagnosed with bipolar disorder, was admitted to the facility with a physician's order for several medications, including lithium ER, which should not be crushed. On the morning of May 29, 2024, Staff 28, an RN, crushed and administered Resident 442's medications in pudding, contrary to the medication guidelines. This action led to the resident experiencing altered mental status and elevated lithium levels, necessitating hospitalization and ICU admission. Despite being notified of the resident's lethargic condition, Staff 28 did not assess the resident, and no medication error documentation was found in the resident's electronic record. Additionally, the facility failed to ensure proper sanitization practices for medical equipment. Resident 39, who has diabetes, had their blood sugar level checked by Staff 28 in the dining room. The glucometer used was cleaned with small alcohol prep wipes, which were not the appropriate sanitizing wipes as per facility protocol. Staff 28 was unaware of the correct sanitizing procedure, indicating a lack of adherence to professional standards and training in infection control practices.
Failure to Supervise Resident During Meal
Penalty
Summary
The facility failed to provide adequate supervision to a resident with known swallowing difficulties, leading to a risk of aspiration or choking. Resident 292, who was admitted with dementia and swallowing difficulties, was not properly supervised while eating a peanut butter and jelly sandwich. On the evening of March 14, 2024, Staff 24 assisted the resident into the Central Dining Room and provided the sandwich before leaving to chart at the Central Nursing Station. Staff 24 claimed to have asked Staff 26, an LPN, to supervise the resident, but Staff 26 was also charting at the Central Nursing Station and was unaware that the resident was eating. Interviews with various staff members, including a CNA, LPN-Resident Care Manager, and ST-Rehab Manager, revealed that close supervision required staff to remain within arm's length or sit at the same or an adjoining table with the resident. However, Staff 26 did not supervise the resident as required. The Director of Nursing Services confirmed that the dining room could not be observed from the Central Nursing Station, acknowledging that the resident did not receive the necessary close supervision while eating.
Deficiencies in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to thoroughly assess and monitor the respiratory status of two residents, leading to deficiencies in their care. Resident 17, who was admitted with chronic obstructive pulmonary disease, congestive heart failure, and pulmonary hypertension, experienced a moist cough and required continuous oxygen. Despite these symptoms, thorough respiratory assessments were not documented after 9/25/24, and the resident continued to exhibit respiratory symptoms without adequate monitoring. Staff acknowledged the lack of thorough assessments, which were expected to include lung sounds, cough, temperature, and oxygen saturation. Resident 42, diagnosed with sleep apnea, had a care plan requiring the use of a CPAP machine, which was to be cleaned daily. However, there were no nursing notes documenting the care of the CPAP machine, and the resident reported that the machine was rarely cleaned. Staff indicated that the task was often not completed due to the resident's request to return later when the machine was not in use. The DNS acknowledged the need for the CPAP machine to be cleaned as ordered, despite its frequent use.
Staffing Deficiencies Lead to Delayed Care for Residents
Penalty
Summary
The facility failed to provide sufficient staffing for two residents, leading to unmet needs and delayed care. Resident 42, who was admitted with heart failure, diabetes, and severe obesity, required substantial assistance with toileting hygiene. Despite a care plan indicating the need for intermittent supervision, Resident 42 frequently waited up to an hour for assistance, as confirmed by both the resident and staff members. Observations showed prolonged call light response times, and staff reported that the hall was understaffed, particularly on weekends. The administrator acknowledged that staffing needs based on Resident 42's acuity were not met, and call light response times needed improvement. Resident 76, diagnosed with quadriplegia, was dependent on staff for all care and required a sip and puff call light to request help. However, the call light was not within reach, and staff failed to ensure it was properly placed. On one occasion, a CNA turned off the call light without providing care or repositioning it, resulting in a delay in assistance. Staff reported being mandated to work extra shifts and noted that the facility did not account for the high number of residents requiring two-person assistance when determining staffing levels. The DNS expected call lights to be answered within 12 to 15 minutes, but this standard was not met for Resident 76.
Medication Error Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the case of a resident with bipolar disorder who was admitted in April 2024. The resident was prescribed lithium ER, which should not be crushed, chewed, or broken. However, on May 29, 2024, a registered nurse (RN) crushed the resident's lithium medication and administered it in pudding due to the resident's difficulty swallowing pills. This action led to the resident experiencing altered mental status and mildly elevated lithium levels, resulting in hospitalization and transfer to the ICU. The RN and the Director of Nursing Services (DNS) both acknowledged the error, and no documentation of the medication error was found in the resident's electronic record.
Improper Sanitization of Glucometer Between Uses
Penalty
Summary
The facility failed to ensure proper sanitization of a community use glucometer between resident uses, specifically for a resident with diabetes who was admitted in February 2024. On October 9, 2024, a registered nurse (RN) was observed checking the resident's capillary blood glucose (CBG) level in the dining room and subsequently cleaning the glucometer with small alcohol prep wipes. The RN stated that she always used alcohol prep wipes for sanitizing the glucometer and was unaware of any other sanitizing wipes. Later, two licensed practical nurses (LPNs) confirmed that the glucometer should be sanitized with the proper sanitizing wipes, indicating a failure in following the correct infection prevention and control procedures.
Failure to Follow Physician Orders and Care Plans
Penalty
Summary
The facility failed to follow physician orders and care plans for three residents, leading to unmet care needs. Resident 9, diagnosed with chronic pain syndrome, did not receive prescribed Morphine on two occasions due to the facility running out of the medication. This resulted in the resident experiencing increased pain and distress. The facility staff acknowledged the failure to administer the medication as ordered by the physician. Resident 3, diagnosed with vascular dementia and requiring assistance with ADLs, was left alone in a bathtub for over an hour, during which the resident became unresponsive. The care plan, which required one-person assistance with bathing, was not followed. Staff interviews confirmed that the resident was left unattended and that the responsible staff member no longer worked at the facility. Resident 5, diagnosed with fibromyalgia, did not receive the prescribed colchicine for 12 days due to issues with acquiring the medication from the pharmacy. The DNS acknowledged the failure to administer the medication as ordered.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 144 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — 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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Eugene
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Green Valley Rehabilitation Health Center | 2 mi | ★★★★★ | 25 | 0 |
| Avamere Rehabilitation Of Eugene | 3.2 mi | ★★★★★ | 17 | 1 |
| Hillside Heights Rehabilitation Center | 3.6 mi | ★★★★★ | 14 | 0 |
| South Hills Rehabilitation Center | 3.9 mi | ★★★★★ | 22 | 1 |
| Valley West Health Care Center | 3.9 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 July 2026) and official state health department websites.