Above average — CMS composite of the measures below.
The next survey window likely opens around April 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 Creekside Health And Rehabilitation Of Cascadia during CMS and state inspections, most recent first.
Stained and Discolored Hallway Carpeting: A resident with quadriplegia reported stained carpets in several spots, and survey observation found multiple areas of stained, discolored, worn, and dingy carpeting throughout resident hallways, including large dark stains and bleach stains near room doorways. The Maintenance Director and CEO both acknowledged the carpeting needed to be replaced.
Improper Storage of Controlled Medications in Narcotic Refrigerator: The narcotic med refrigerator repeatedly stayed well below the accepted 36 to 46 degree F range, with automatic logs showing temperatures in the 20s and low 30s over an extended period. An unopened bottle of liquid lorazepam, an unopened vial of injectable lorazepam, and an open bottle of liquid lorazepam for a discharged resident were found inside the refrigerator, and the DON/CNO stated maintenance had not been notified of the low temperatures. The pharmacist stated lorazepam efficiency would be affected if kept below freezing for that long.
Delayed urine specimen processing affected two residents with suspected UTI. One resident’s UA specimen could not be processed because the sample was not identifiable, and the replacement specimen and results were delayed. Another resident’s urine sample sat in the lab pickup box until several days later, and the culture was not performed because the specimen exceeded stability requirements.
A resident with anxiety who required moderate assistance for transfers and toileting was subjected to inappropriate and disrespectful behavior by a CNA, including profane language, rough handling, and dismissive comments when requesting a female caregiver. Multiple grievances were filed, and staff interviews corroborated concerns about the CNA's conduct, leading to the identification of a deficiency in upholding resident dignity and respect.
A resident with congestive heart failure received Enestro, a heart and blood pressure medication, despite physician orders to withhold it if the systolic blood pressure (SBP) was below 120. The medication was administered on three occasions when the resident's SBP was below the threshold, as acknowledged by various staff members, including a DNS, LPN, RN, and CMA.
A resident with hand tremors was not provided with adaptive eating utensils as recommended by the RD. Despite an order for adaptive flatware, observations showed the resident's meal trays lacked these utensils. Staff interviews revealed the order was not included on tray tickets, resulting in the oversight.
Stained and Discolored Hallway Carpeting
Penalty
Summary
The facility failed to maintain a homelike environment for 1 of 1 facility reviewed. Resident 38, who was admitted in 2023 with a diagnosis of quadriplegia, stated that the carpets were stained in several spots and needed to be replaced. Observation of all facility halls showed multiple areas of stained and discolored carpeting throughout resident hallways, including large dark stains on the carpeted walking surfaces and multiple light-colored bleach stains adjacent to resident room doorways. The carpets appeared worn, dingy, and discolored, resulting in an unclean appearance. The Maintenance Director observed the 400, 600, and 700 halls and confirmed the carpets were stained in multiple areas, with large dark stains and multiple light-colored bleach stains adjacent to resident rooms. The CEO also acknowledged that the carpets needed to be replaced.
Improper Storage of Controlled Medications in Narcotic Refrigerator
Penalty
Summary
The facility failed to store medications properly for 1 of 3 medication refrigerators. The narcotic refrigerator was intended to store controlled medications, including liquid lorazepam and injectable lorazepam, but the temperature log showed repeated readings far below the accepted medication refrigerator range of 36 to 46 degrees Fahrenheit over the prior 30 days. The recorded temperatures were consistently between about 23.9 and 31.64 degrees Fahrenheit, and Staff 2 stated the refrigerator temperatures were monitored automatically every 12 hours with notifications sent to her phone when out of range. On 5/21/26, Staff 2 observed the narcotic refrigerator with an unopened bottle of liquid lorazepam, an unopened vial of injectable lorazepam, and an open bottle of liquid lorazepam for a resident who discharged on 5/20/26. The resident had received two doses of lorazepam, one on 5/19/26 and one on 5/20/26. Staff 2 stated the pharmacy was notified and the medications would be discarded, and acknowledged that the expected process when the refrigerator temperature was too low was to turn the temperature up and replace the medications, but this was not followed. Staff 2 also stated maintenance had not been notified of the low temperatures. The pharmacist stated lorazepam efficiency would be affected if kept in a refrigerator below freezing temperatures for that long.
Delayed Urine Specimen Processing and Lab Follow-Up
Penalty
Summary
The facility failed to provide timely lab services for two residents who had urine specimens collected for suspected urinary tract infection. One resident, admitted with acute pyelonephritis and cognitively intact, reported burning with urination and had a UA ordered; the specimen was sent to the lab the same day, but the facility later learned the specimen could not be processed because the resident’s name was not identifiable on the sample. A new UA order was obtained several days later, a new urine specimen was collected and sent, and the lab results were not returned to the facility until several days after that. The resident later returned to the hospital after a fall and was diagnosed with a UTI while hospitalized. A second resident, admitted with a shoulder fracture, had a provider visit note documenting suspected UTI with urine retention and an order to send a urine sample for evaluation. The urine sample was collected and placed in the laboratory box for courier pickup, but the specimen was not received by the lab until several days later. The final diagnostic report showed many bacteria in the urine and a culture was to be completed, but the culture was not performed because the specimen quality was inadequate and the urine sample exceeded the stability required for the test.
Failure to Ensure Resident Dignity and Respect During Care
Penalty
Summary
A deficiency occurred when a resident, admitted with anxiety and cognitively intact, was not treated with dignity and respect by a CNA. The resident required moderate assistance for transfers and toileting and had interventions in place for anxiety, including one-on-one support. On the evening or night shift, the resident requested a female CNA for assistance with a shower, but was told by the male CNA that none was available and was met with an inappropriate comment. During toileting and transfer assistance, the CNA reportedly used profane language, handled the resident roughly by grabbing and tossing their legs onto the bed, and threw the resident's walker into the corner. The resident reported feeling frightened and cried during the incident, while the CNA continued to use inappropriate language and displayed aggressive behavior. Multiple grievances were filed against the CNA by residents, and staff interviews confirmed that the CNA was perceived as gruff and rough around the edges. The CNA admitted to possibly using profanity and moving equipment roughly, though he denied intentional harm. The facility's Director of Nursing and Regional RN Consultant stated that they ruled out abuse and neglect, citing inconsistencies in the resident's account, but the incident was substantiated through resident and staff interviews and the facility's investigation.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to adhere to physician orders for a resident diagnosed with congestive heart failure, leading to the administration of unnecessary medication. The resident was prescribed Enestro, a heart and blood pressure medication, with specific instructions to withhold the medication if the resident's systolic blood pressure (SBP) was below 120. Despite this, the medication was administered on three separate occasions when the resident's SBP was below the specified threshold: on January 2nd with an SBP of 118, on January 4th with an SBP of 110, and on February 1st with an SBP of 104. Staff members, including a DNS, LPN, RN, and CMA, acknowledged the error in administering the medication contrary to the physician's orders, which placed the resident at risk for adverse side effects.
Failure to Provide Adaptive Eating Utensils
Penalty
Summary
The facility failed to provide assistive devices for a resident who required them for eating due to hand tremors. The resident was admitted with a diagnosis of anxiety and had difficulty grasping a fork, as noted in a nutrition evaluation. The registered dietitian recommended adaptive flatware to be used for all meals, and an order was placed accordingly. However, observations on multiple occasions revealed that the resident's meal trays did not include the adaptive flatware. Staff interviews indicated that the adaptive ware was supposed to be added during the tray line process in the kitchen, but the order was not reflected on the tray tickets, leading to the oversight.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Eugene
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| South Hills Rehabilitation Center | 0.6 mi | ★★★★★ | 22 | 1 |
| Cascade Manor | 0.6 mi | ★★★★★ | 4 | 0 |
| Hillside Heights Rehabilitation Center | 1.6 mi | ★★★★★ | 14 | 0 |
| Avamere Rehabilitation Of Eugene | 2.2 mi | ★★★★★ | 17 | 1 |
| Valley West Health Care Center | 3.6 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.