Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Keizer Nursing And Rehabilitation during CMS and state inspections, most recent first.
Staff were observed handling unclean meal tickets and then, without changing gloves or performing hand hygiene, touching food and clean items such as bread rolls, plates, silverware, desserts, and condiments during meal service. Facility staff acknowledged that this practice did not meet sanitary standards.
Surveyors found that a refrigerator used for resident food storage contained outdated and unlabeled food items, including containers with old dates, take-out food, and opened ice cream with no open date. Some items were not marked with resident room numbers. The Dietary Manager stated monitoring had not been done recently, and facility policy required timely removal and proper labeling of food.
A resident with spinal stenosis and pain did not receive prescribed tizanidine as ordered because the medication was not reordered in a timely manner, resulting in missed doses and increased pain. Staff interviews and records confirmed ongoing issues with timely medication reordering, unclear responsibility among nursing staff, and that the pharmacy was not contacted for a refill until after the medication had run out.
Staff did not notify the physician about significant weight increases for a resident with chronic heart failure, hypertension, and a pacemaker, despite physician orders to do so. Documentation showed multiple instances of weight gain above the specified threshold without evidence of physician notification. An LPN could not recall making or documenting the notification, and facility leadership confirmed that staff were expected to follow the order.
A resident with diabetes and kidney failure sustained a fall during physical therapy, resulting in multiple right leg fractures confirmed by hospital evaluation. Despite the severity of the injury, facility staff did not submit a required incident report to the state agency within 24 hours, based on a misinterpretation of reporting requirements.
A resident with diabetes, decreased mobility, and cognitive deficits did not receive required nail care, as evidenced by long, jagged fingernails and lack of documentation in the clinical record. Staff confirmed the absence of nail care and documentation, despite facility expectations for nurses to provide and record this care for diabetic residents.
A resident with PTSD, anxiety, and a history of trauma did not receive trauma-informed care. Required assessments and documentation were incomplete, and the care plan lacked identification of trauma triggers or person-centered interventions. Staff reported the resident frequently referenced past traumas and exhibited distress, but the care plan and psychosocial evaluation did not address these needs.
Expired medications, including nutritional supplements, aspirin, and bisacodyl suppositories, were found in the medication storage room and on a medication cart. Staff confirmed that expired medications were expected to be removed and destroyed, but these items remained accessible during the survey.
Unsanitary Food Handling During Meal Service
Penalty
Summary
Staff in the facility's kitchen failed to maintain sanitary practices during meal preparation and service. Specifically, a cook and a dietary aide were observed handling resident-completed meal tickets with gloved hands and then, without changing gloves or performing hand hygiene, directly touching bread rolls, plates, silverware, desserts, and condiments that were served to residents. This practice was repeated throughout the meal service. Staff members, including the dietary manager and administrator, acknowledged that the meal tickets were considered unclean surfaces and that food and clean items should not be handled after touching them.
Outdated and Unlabeled Food Items Found in Resident Refrigerator
Penalty
Summary
The facility failed to ensure that the resident food refrigerator was free of outdated food items. During an observation, the refrigerator contained food containers with dates from over a month prior, take-out food with similarly old dates, and a jar of soup with no date. The freezer section also had two opened and partially used ice cream containers with no open date. Some food containers did not have resident room numbers identified. The Dietary Manager acknowledged responsibility for monitoring the refrigerator but admitted it had not been done recently. Facility policy required foods to be removed after three days unless unopened and unexpired, and all items should be marked with resident room numbers. The Director of Nursing Services confirmed that staff should be marking foods with the room number of the resident.
Failure to Timely Reorder and Administer Physician-Ordered Medication
Penalty
Summary
The facility failed to follow physician orders for medication administration for one resident with diagnoses including spinal stenosis and pain. The resident had physician orders for tizanidine HCl 2 mg tablets to be administered three times daily and as needed for muscle spasms, as well as oxycodone for pain. Documentation showed that the resident's tizanidine was not administered as ordered because the medication was not available; progress notes indicated the facility was out of the medication, and the pharmacy was not contacted for a refill until after the resident had already missed doses. The Medication Administration Record (MAR) and staff interviews confirmed that the resident experienced increased pain and breakthrough pain due to the unavailability of the muscle relaxant. Staff interviews revealed that nurses, including agency staff, were responsible for reordering medications but did not consistently do so in a timely manner. There was a lack of clarity among staff regarding who was responsible for monitoring medication reorders, and ongoing issues were reported with timely ordering of non-narcotic medications. The pharmacist confirmed that the facility did not request a refill for the resident's tizanidine until after the medication had run out. The resident reported increased pain and distress during the period when the medication was unavailable.
Failure to Notify Physician of Significant Weight Changes
Penalty
Summary
Facility staff failed to notify the physician regarding significant weight changes for a resident with chronic heart failure, hypertension, and a pacemaker. The physician's order required daily weights and notification if the resident gained three or more pounds in 24 hours or exceeded 283 pounds. Review of the resident's records showed multiple instances where the resident's weight exceeded these parameters, but there was no documentation that the physician was notified. When interviewed, an LPN could not recall notifying the physician or documenting such notification, and both the Administrator and DNS confirmed that staff were expected to follow the physician's order and report weight changes as directed.
Failure to Timely Report Fall with Major Injury
Penalty
Summary
The facility failed to report a fall with major injury to the State Survey Agency within 24 hours as required. A resident with diabetes and kidney failure, admitted in December 2023, sustained a fall while working with physical therapy. Following the fall, the resident complained of pain, and x-rays were ordered. The next day, the provider ordered the resident to be sent to the hospital for further evaluation, where multiple fractures in the right leg were identified. Despite these findings, the former Director of Nursing Services (DNS) did not file a Facility Reported Incident (FRI), believing it was unnecessary since the injuries were not considered serious bodily injury according to her interpretation of the FRI form. The current DNS also acknowledged that an FRI was not submitted for the incident.
Failure to Provide and Document Required Nail Care for Dependent Diabetic Resident
Penalty
Summary
A resident with diabetes, osteoarthritis, fragile skin, decreased mobility, and cognitive deficits was admitted to the facility and had a care plan intervention to keep fingernails short. The clinical record showed an order for daily shift fingernail care every Friday, which was discontinued, and no further documentation of diabetic nail care was found for April and May 2025. Observations on two occasions revealed the resident's fingernails were approximately half an inch long and jagged, and the resident expressed concern about potential injury from the nails. Staff confirmed the resident's nails were long and that there was no documentation of nail care provided. Facility policy required nurses to provide and document nail care for diabetic residents, but this was not done for the resident in question.
Failure to Provide Trauma-Informed, Person-Centered Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident with a documented history of PTSD, anxiety, altered mental status with auditory hallucinations, and a history of sexual and physical trauma. The resident's PASRR Level I screening indicated serious mental illness, but required sections were left incomplete and there was no documentation of further assessment. A subsequent mental illness screening confirmed the need for specialized services, yet the necessary follow-up and documentation were not completed within the required timeframe. The resident's care plan acknowledged PTSD but did not document the trauma history or identify individual triggers, and interventions were limited to a psychiatric consult without person-centered details. The MDS and CAAs did not reference trauma-informed care planning, and the psychosocial evaluation failed to incorporate the resident's trauma history or PTSD-related concerns. Staff interviews revealed that the resident frequently referenced past traumas during personal care and exhibited behaviors consistent with re-experiencing traumatic events, such as mistrust, verbal aggression, and distress triggered by loud noises or unfamiliar staff. Staff acknowledged the lack of appropriate follow-up on the PASRR and incomplete documentation, as well as the absence of identified triggers and person-centered interventions in the care plan. The failure to incorporate trauma-informed, person-centered care planning placed the resident at risk for unmet psychosocial needs and a potential decline in quality of life.
Expired Medications Found in Storage Room and Medication Cart
Penalty
Summary
Surveyors observed that expired medications were present in both the medication storage room and on a medication cart. Specifically, three bottles of Pro Stat AWC liquid, one bottle of aspirin 325 mg tablets, and thirty-three boxes of bisacodyl 10 mg suppositories, all with expiration dates in April 2025, were found in the medication storage room. Additionally, one bottle of aspirin 325 mg tablets with the same expiration date was found on medication cart number 2. Staff interviews confirmed that the facility's expectation was for expired medications to be removed from circulation and destroyed, but these expired items remained accessible at the time of the survey.
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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 Keizer
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avamere Court At Keizer | 1.2 mi | ★★★★★ | 19 | 0 |
| Windsor Health And Rehabilitation | 2.7 mi | ★★★★★ | 6 | 0 |
| Tierra Rose Care Center | 3.3 mi | ★★★★★ | 2 | 0 |
| Avamere Transitional Care At Sunnyside | 6.6 mi | ★★★★★ | 0 | 0 |
| Salem Transitional Care | 7.2 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.