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 August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Regency Albany during CMS and state inspections, most recent first.
Kitchen sanitation, hair restraint, and ice drainage deficiencies: The Dietary Mgr was observed in the prep kitchen without a hair restraint while handling food tasks, and kitchen areas showed poor sanitation, including debris on the ice machine drain components, residue on a freezer wall, food on the freezer floor, and an open package of frozen hamburger patties. The facility also had an ice machine drain tube in direct contact with the drain without the required air gap, and the Dietary Mgr, Admin, and Regional President confirmed the condition.
The facility failed to follow physician orders for two residents. One resident with diabetes and ESRD requested PRN ondansetron for nausea, but the LPN did not administer it until hours later, and the resident also missed multiple scheduled AM meds before leaving for dialysis, including insulin and several antihypertensive and renal medications. Another resident with hearing loss had impacted ear wax and was ordered Debrox for both ears, but the MAR/TAR showed no evidence the order was implemented and staff confirmed it was not given.
Infection control practices were not followed for a resident with diabetes and residents on contact precautions. An LPN disinfected a shared glucometer with an alcohol pad instead of an approved disinfecting wipe, despite facility policy and the device manual requiring an approved wipe. Staff also entered the room of an RSV-positive resident on contact precautions without the required gown, gloves, or surgical mask, and a dietary aide and an activities director were observed handling trays and entering the room without following the posted precautions or cleaning a shared clipboard.
Failure to Respect Resident Care Preferences and Dignity: A cognitively intact resident with depression and diabetes stated only female house staff should assist with care, but the former DNS allegedly told the resident that male CNA staff and new CNA staff had to provide care. An ADON/Activity Director witness reported the conversation was rude, condescending, and demeaning, and the resident felt disregarded.
A resident with hemiplegia and two cognitively intact residents were affected by unsafe room conditions. Two residents reported a toilet that flushed continuously and had been broken for a long time, and CNAs confirmed the issue had been observed and reported. Another resident was observed nearly falling while trying to open an old dresser that staff said was hard to open and not safe to use.
A resident with bipolar disorder and PTSD was receiving buspirone 10 mg BID, and pharmacy noted the psychotropic was due for a GDR because the resident was not experiencing anxiety. The provider agreed to reduce the dose to 5 mg BID, but the order was not implemented in a timely manner, and an LPN Resident Care Manager acknowledged the delay.
Failure to Provide Personal Hygiene: A resident with stroke-related deficits and moderate cognitive impairment depended on staff for personal hygiene, but staff did not trim long fingernails, clean under the nails, or remove facial hair. Observations showed brown debris under the nails and facial hair on the chin and upper lip, while CNAs and LPNs gave inconsistent accounts of whether nail care and other hygiene tasks were needed or completed.
Failure to provide ROM support and splinting for two residents. One resident with stroke-related right-sided impairment and moderate cognitive impairment had a contracted right arm, was not wearing the prescribed splint, and staff reported they did not complete the home exercises or ROM activities. Another resident with Parkinson’s disease and severe cognitive impairment had a left-hand contracture, but staff did not offer or assist with the ordered palm protector, and the resident was repeatedly observed without it in place.
A resident with severe cognitive impairment was found in another resident's room engaged in inappropriate sexual contact, with no memory of the event and exhibiting unusual behavior afterward. Despite the incident and the other resident's history of inappropriate conduct, the facility did not implement or document any interventions to ensure safety, and the family was not promptly notified.
A resident's allegations of sexual and verbal abuse were not reported to the State Survey Agency within the required two-hour timeframe. The incidents were reported several days after they occurred, and the facility administrator confirmed the delay in reporting.
The facility failed to implement proper infection control and sanitation practices for residents with C-Diff and other infections. A resident with C-Diff was not placed on contact precautions timely, and staff used ineffective cleaning products. Another resident with a pressure ulcer received unsanitary wound care. Staff also failed to use PPE and proper hand hygiene during medication administration and high-contact care activities.
Two residents experienced verbal abuse by staff in a LTC facility. One resident, with anxiety and depression, was left feeling stripped of dignity after a CNA refused to get assistance during care. Another resident, with cerebral palsy, faced aggressive behavior from the Kitchen Manager during a grievance discussion. Witnesses confirmed the inappropriate conduct, leading to a delayed abuse investigation.
The facility failed to document and follow up on advance directives for several residents, including those with leg fractures, open wounds, and malnutrition. Despite providing advance directive packets during care conferences, there was no follow-up to ensure completion or documentation, placing residents at risk of not having their healthcare decisions honored.
The facility did not provide a homelike dining environment in three dining rooms. Meals were left on trays, and tables lacked decorations and tablecloths. The administrator acknowledged that meals should feel like home and trays should be removed unless requested by residents.
Facility staff failed to follow professional standards for medication administration and wound care, affecting four residents. An LPN administered medications late and without checking blood pressure, while another staff member provided inadequate wound care by not sanitizing hands or changing gloves. Additionally, a resident did not rinse their mouth after using an inhaler, and medications were given without proper timing or checks.
A long-term care facility reported a medication error rate of 18.92%, with errors including late administration, failure to check blood pressure, improper handling of medications, and not following specific medication instructions. These incidents involved residents with heart disease, respiratory failure, and thyroid disorder, and were attributed to a lack of guidance for LPNs on handling late medication administration.
A resident with Parkinson's disease and hand contractures was unable to use the facility's call light system, leading to unmet hydration needs. Despite a revised care plan, the resident had to yell for assistance, as confirmed by staff. The care plan lacked interventions for the resident's inability to use the call light and the need for frequent fluid offers, which was acknowledged by the Resident Care Manager.
A resident with bipolar disorder was inaccurately assessed regarding their discharge preferences. Despite the 9/28/24 Annual MDS indicating the resident did not want to discuss leaving the facility, interviews in November revealed the resident's desire to discharge to a home in Corvallis or Philomath. Staff confirmed the MDS information was incorrect, and the Regional Nurse acknowledged the error.
A resident with bipolar disorder was not provided with the necessary mental health evaluations as indicated by a PASRR Level 1 form. Despite the form highlighting serious mental illness indicators, the facility did not complete further evaluations, as acknowledged by the Social Service Manager.
A resident did not receive Catholic communion as scheduled due to a COVID outbreak, and the facility failed to document spiritual activity participation. The resident, with anxiety and depression, was cognitively intact and had minimal participation in spiritual activities over several months.
A facility failed to follow physician orders for insulin administration for a resident with diabetes. The resident had orders for 13 units of Humalog insulin before each meal, to be held if the CBG level was less than 100. However, an LPN held the insulin on two occasions when the CBG levels were above 100, due to a misunderstanding of standing orders. The Regional Nurse confirmed that the physician's orders should have been followed.
Two residents experienced deficiencies in pressure ulcer care and infection control. A resident's blisters were not documented as Stage 2 pressure ulcers, and another resident's wound care was compromised by an LPN's failure to maintain proper infection control practices, including not sanitizing hands and using soiled gloves and scissors.
The facility failed to ensure a safe environment for two residents, leading to potential injury risks. A resident with hoarding behaviors was injured by a falling bedside table, which was not promptly evaluated. Another resident, requiring fall mats due to chronic heart failure and dementia, did not have them in place as per their care plan, and the LPN was unaware of this omission.
A facility failed to provide and document catheter care for a resident with a Stage 4 pressure ulcer. The resident was observed with blood in the catheter tubing, which they stated was normal after a catheter change. However, there was no documentation in the Treatment Administration Record or Nursing Progress Notes for catheter care, such as flushing, cleaning, or changing the catheter. An LPN confirmed the lack of documentation in the resident's electronic record.
The facility failed to provide proper respiratory care for two residents, leading to potential infection risks. A resident's CPAP mask was stored improperly with a used tissue nearby, while another's BiPAP machine was unsanitarily placed on a nightstand and bedrail. Staff acknowledged the inadequate storage practices and policy shortcomings.
A resident with cerebral palsy, dependent on staff for toileting, reported that caregivers made derogatory comments about the smell of their feces, leading to feelings of embarrassment and shame. The incident was not documented in the resident's progress notes, and the facility administrator confirmed the termination of the involved CNA's contract due to the inappropriate comment.
A facility failed to timely report an abuse allegation to the SSA for a resident with anxiety and depression. The incident occurred on a weekend, and the report was delayed due to a holiday, being sent the following Tuesday. The Administrator could not recall the report timing, and the DNS confirmed the delay, placing residents at risk.
Kitchen sanitation, hair restraint, and ice drainage deficiencies
Penalty
Summary
The facility failed to ensure dietary staff wore appropriate hair restraints, maintained sanitary food storage and kitchen cleanliness, and kept the ice machine drainage in a sanitary condition. During the initial kitchen tour, the grate, drain, and plastic outlet tube for the ice machine were covered in brown debris, a red residue was visible on the wall behind the shelf in the walk-in freezer, frozen vegetables were on the floor in the walk-in freezer, and an open and unsealed package of frozen hamburger patties was present in the walk-in freezer. The Dietary Manager stated staff were expected to clean the ice machine components weekly, sweep between meals, clean food storage areas every evening, and check the walk-in freezer for open and unsealed foods, and later acknowledged the observed cleaning deficiencies. The Dietary Manager was also observed in the prep kitchen without a hair restraint while entering the area and while checking the internal temperature of mashed potatoes. He stated dietary staff were expected to wear hair restraints at all times in the kitchen and that he should have worn one before entering the prep kitchen. In addition, the facility’s ice machine drainage was observed without the required air gap, with the plastic outlet tube coiled and in direct contact with the drain inside the prep kitchen. The Dietary Manager acknowledged the lack of an air gap, and the Administrator and Regional President later confirmed there was no air gap to prevent contamination from backflow of water.
Failure to follow physician orders for medications and ear treatment
Penalty
Summary
The facility failed to follow physician orders for Resident 4, who was admitted with diabetes and end stage renal failure and had a BIMS score of 12 indicating moderate cognitive impairment. On 3/25/26 at 8:07 AM, Resident 4 requested a PRN anti-nausea medication from an agency LPN during blood sugar checks, but the LPN checked the blood sugar, left the room, administered insulin, and did not give the PRN anti-nausea medication at that time. The MAR later showed ondansetron was administered at 10:50 AM, 2 hours and 43 minutes after the resident requested it. Staff later stated the resident reported nausea at about 6:30 AM and that nursing staff were notified, and the agency LPN acknowledged the medication was not assessed or provided when requested. The facility also failed to administer Resident 4’s scheduled morning medications before the resident left for a dialysis appointment on 2/27/26. The MAR and Licensed Nurse Admin Record showed multiple ordered medications were not given and were charted as absent from home, including insulin glargine, insulin aspart, amlodipine, b complex with c, bupropion ER, losartan, multivitamin, sertraline, vitamin D3, Bumex, carvedilol, clonidine, and sevelamer carbonate. Progress notes indicated staff documented the resident was at dialysis and unable to receive the medications, and the provider was notified of the missed administrations. The facility also failed to follow a physician order for Resident 7, who had unspecified hearing loss and a BIMS of 14 indicating cognitive intactness. A provider progress note documented impacted ear wax in the left ear and ordered Debrox for both ears, but the MAR and TAR for 3/2026 showed no indication of the order and the medication was not administered.
Infection Control Failures With Shared Glucometer Disinfection and Contact Precautions
Penalty
Summary
The facility failed to ensure staff used appropriate infection control practices for residents on contact precautions and failed to disinfect glucometers according to manufacturer recommendations. The facility's policy required blood glucose meters to be disinfected with an approved disinfecting wipe for blood borne pathogens, and the manufacturer manual for the EvenCare G2 Blood Glucose Monitor also required an approved disinfecting wipe. Resident 21, who had diabetes, was observed on 3/26/26 when an LPN used the shared glucometer for a blood sugar check and then disinfected it with an alcohol pad wipe before placing it back in the medication cart. The LPN stated the glucometers were shared and acknowledged an alcohol pad was not an approved disinfectant wipe. The DNS stated staff were expected to use an approved disinfectant wipe, and the nurse consultant later acknowledged after checking the manufacturer guidelines that an alcohol pad wipe was not approved. Resident 36, who had CHF and was RSV positive, was on contact precautions with signage posted on the room door and the care plan directing staff to follow contact and droplet precautions. A dietary aide entered the resident's room with a clipboard without a gown, gloves, or surgical mask, removed the resident's tray, returned to the hallway cart, re-entered the room without hand hygiene, and handed the roommate the clipboard without cleaning it. The dietary aide stated she did not need to wear a gown, gloves, or surgical mask because she was not providing direct care and confirmed she did not clean the clipboard each time it was handled. The dietary manager stated dietary staff had not been trained on transmission-based precautions, and the IP later confirmed all staff needed to wear a gown and gloves before entering rooms of residents on contact precautions and a surgical mask if within three feet of an RSV-positive resident. In another observation, an activities director entered a room with a contact precautions sign and delivered a meal tray without donning a gown and gloves, stating she was unsure if they were needed.
Failure to Respect Resident Care Preferences and Dignity
Penalty
Summary
The facility failed to ensure Resident 44’s right to a dignified existence when staff did not respect the resident’s stated preference for only female house staff to provide care. Resident 44 was admitted in 2023 with diagnoses including depression and diabetes, and the 10/29/25 annual MDS showed a BIMS of 15, indicating the resident was cognitively intact. During an interview, Resident 44 stated that Staff 11, the former DNS, told the resident that new CNA staff and male CNA staff had to provide care, and the resident said this conversation was witnessed by Staff 4, the Activity Director. Staff 4 stated the resident requested her presence during a July 2025 conversation about care preferences and reported that Staff 11 spoke in a rude, condescending, and demeaning tone, stating, “you will have to let men take care of you,” which upset the resident. Staff 11 acknowledged having a conversation with the resident about care with Staff 4 present but did not recall speaking in a rude, condescending, or demeaning tone. Staff 1 stated she expected all staff to speak to residents with dignity, respect, and kindness and acknowledged the findings.
Unsafe Furniture and Nonfunctional Toilet
Penalty
Summary
The facility failed to provide a functional toilet for Residents 38 and 40 and failed to provide safe furniture for Resident 31. Resident 38 was admitted with diagnoses including seizures, and a 1/9/26 Quarterly MDS showed a BIMS score of 15, indicating cognitive intactness. Resident 40 was admitted with diagnoses including heart failure, and a 3/19/26 Quarterly MDS showed a BIMS score of 15, also indicating cognitive intactness. On 3/24/26, Residents 38 and 40 stated the toilet flushed continuously when used, had been broken for a long time, was loud, and could run for up to 40 minutes. Resident 38 stated staff had called a plumber, but the toilet was still broken. Staff interviews confirmed the toilet problem had been observed by multiple CNAs, and one CNA stated the issue had been reported to the DNS. Another CNA stated she did not notify maintenance or enter a work order because she thought staff were aware. The Maintenance Director later inspected the toilet and found a damaged part, stating he had the part on hand and would repair it. Resident 31, admitted with diagnoses including seizures and hemiplegia, had a 1/14/26 Quarterly MDS showing a BIMS score of 14. Staff stated Resident 31's dresser was hard to open and not easily accessible, and the resident was observed almost falling while trying to open it. Staff acknowledged the dresser drawers were old and not safe for the resident to use.
Delayed GDR of Psychotropic Medication
Penalty
Summary
The facility failed to implement a gradual dose reduction (GDR) of a psychotropic medication in a timely manner for one resident who was reviewed for medications. The resident was admitted in 2023 with diagnoses including bipolar disorder and post-traumatic stress disorder. A pharmacy recommendation dated 3/12/26 noted the resident was receiving buspirone 10 mg twice daily, identified as a psychotropic medication, and was due for a GDR because the resident was not experiencing anxiety; the recommendation was to reduce the dose to buspirone 5 mg twice daily. The provider agreed to the GDR on 3/13/26, and a physician order dated 3/24/26 directed the resident to start buspirone 5 mg twice daily. On 3/27/26, an LPN Resident Care Manager acknowledged that the resident's GDR for buspirone 5 mg twice daily was not implemented timely.
Failure to Provide Personal Hygiene
Penalty
Summary
The facility failed to provide personal hygiene for Resident 9, who was admitted with diagnoses including stroke affecting the right side of the body and had a 2/11/26 Significant Change MDS showing a BIMS score of 9 and dependence on staff for personal hygiene. The 3/24/26 TAR indicated an LPN did not perform nail care because it was not needed. During observations from 3/23/26 through 3/27/26, Resident 9 was seen with fingernails that were not trimmed and were about 1/2 to 1/3 inches long, a brown substance in the fingernails, and facial hair on the chin and upper lip. On 3/23/26, Resident 9 was observed touching the hair on the chin. Resident 9 acknowledged having long fingernails and stated staff were allowed to provide personal hygiene. A CNA stated Resident 9 required maximum assistance when care was provided and that the resident sometimes touched a soiled brief during continent care, but the CNA did not complete personal hygiene, including removing facial hair or cleaning under the fingernails. Another CNA stated she did not complete personal hygiene after the resident's shower the previous day. An LPN stated the resident required assistance with personal hygiene and said the nails looked okay and did not need trimming, while also not noticing the facial hair. Another LPN stated the resident was diabetic and nail trimming was completed by nurses, and that CNAs could clean under the fingernails daily. The IP/LPN care manager stated staff were expected to complete personal hygiene daily and that nail care and facial hair removal were completed on shower days.
Failure to Provide ROM Support and Splinting
Penalty
Summary
The facility failed to provide equipment and services to maintain or improve range of motion for 2 residents reviewed for mobility. One resident had a history of stroke affecting the right side, moderate cognitive impairment, and dependence on staff for care. Therapy documentation stated the resident was to be fitted for an elbow orthotic, tolerate passive stretch and tone-inhibiting techniques to maintain ROM and prevent skin breakdown, and continue home exercises and facility-directed exercise programs while seated in a wheelchair. During repeated observations, the resident’s right arm remained contracted with the arm bent toward the chest and the right hand in a fist. The resident was not wearing the splint, and the splint was observed on top of the dresser. The resident stated the home exercises on the room white board were not completed. Multiple staff members stated they did not perform the home exercises or ROM exercises, were unsure whether the resident used a splint, and some were unaware of any restorative services. The Director of Rehab stated the resident had participated in home exercises, group exercises, and used a soft splint to prevent further contracture, but also stated the resident was not enrolled in a restorative program and there was no order schedule for splint use. The second resident had Parkinson’s disease, severe cognitive impairment, and impairment in both upper extremities. Therapy documentation indicated the resident required assistance to don and doff a palm protector for the left hand to decrease the risk of further contractures, and the care plan stated the palm protector was to be applied for up to four hours daily. The record showed no evidence that staff offered or assisted the resident to apply the left palm protector. Observations showed the resident had a left-hand contracture and resting tremor, and the palm protector was not in place. Staff stated they were unaware of the palm protector, were unsure how long it was to be worn, or were unable to successfully apply it due to stiffness. Therapy and nursing leadership stated nursing staff were expected to be trained and follow the wear schedule, but nursing staff had not received resident-specific training and were not aware of the daily use requirement.
Failure to Protect Cognitively Impaired Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment, including Alzheimer's dementia and aphasia, from sexual abuse by another resident. The incident occurred when a CNA found the cognitively impaired resident in another resident's room, with her/his hands on the other resident's genitals. The resident was redirected to her/his own room and exhibited unusual behavior afterward, such as refusing care and being naked, which was not typical for this resident. The resident had no memory of the incident, and interviews confirmed the resident's inability to consent due to cognitive loss. The other resident involved had a history of making inappropriate comments and watching pornography in the facility. Despite the incident, a review of the medical record and care plan revealed that no interventions were implemented to ensure the safety of the resident following the event. There was no documentation of new safety measures or care plan updates addressing the incident or the behavior of the other resident. Additionally, the family was not promptly notified of the incident, and the administrator acknowledged that appropriate interventions were not put in place due to delayed reporting.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse and an allegation of verbal abuse involving one resident to the State Survey Agency within the required two-hour timeframe. Specifically, the incident of alleged sexual abuse occurred on 9/19/25 at 9:30 PM but was not reported until 9/22/25 at 2:51 PM, and the incident of alleged verbal abuse occurred on 7/19/25 at 12:41 PM but was not reported until 7/21/25 at 2:30 PM. These delays in reporting were confirmed by the facility administrator during an interview, who acknowledged that the incidents were not reported in a timely manner as required.
Inadequate Infection Control and Sanitation Practices
Penalty
Summary
The facility failed to implement transmission-based precautions and proper sanitation procedures for residents diagnosed with Clostridium difficile (C-Diff) and other infections. Resident 30, who was admitted with C-Diff, was not placed on appropriate contact precautions until several days after admission. Staff used ineffective cleaning products, such as Mycolio disinfectant wipes, which are not effective against C-Diff spores. Additionally, staff were observed not following proper hand hygiene and PPE protocols, leading to potential cross-contamination. Resident 10, who had a Stage 4 pressure ulcer, received wound care that did not adhere to sanitary practices. The staff member performing the wound care did not sanitize her hands before donning gloves, used soiled gloves to handle clean dressing supplies, and did not establish a clean field for the procedure. This lack of proper infection control measures could have compromised the resident's wound healing process. Other residents, such as Resident 19 and Resident 27, also experienced lapses in infection control. Staff were observed handling medications without sanitizing hands or using gloves, and failing to use PPE during high-contact care activities. Resident 195, who had a history of C-Diff, was not placed on contact precautions despite having multiple loose stools documented. These deficiencies highlight a systemic issue in the facility's infection prevention and control practices.
Removal Plan
- The hydration cart and vital sign equipment was sanitized to prevent the spread of infection.
- Current staff on shift were re-educated on transmission-based precautions relative to C-Diff per the CDC guidelines. Soap and water were reinforced as the standard for hand hygiene. Additional education was provided to include donning and doffing of PPE.
- Nurse management would complete ongoing Infection Control rounds on all three shifts, and then conduct random audits on all three shifts.
- New admissions to the facility would be reviewed by the Regional Nurse and IP to ensure that appropriate Infection Control measures were implemented, and Kardex and Care plans updated.
- Resident 30 had her/his room deep-cleaned as well as linens changed. Resident 30 declined a shower but accepted a full bed bath.
- Facility staff would be trained on providing hydration while facility residents were on transmission-based precautions including direction to obtain new water pitchers with each hydration pass.
- Current residents on transmission-based precautions had donning and doffing procedures added to the signage on the residents' doors for easy staff reference.
- Residents on transmission-based precautions were provided individual vital sign equipment while on transmission-based precautions.
- The facility IP would complete further training presented by Oregon Care partners on transmission-based precautions.
- Facility equipment for those on transmission-based precautions would be sanitized utilizing the Clorox Bleach Germicidal wipes with a contact time of three minutes. Education was provided to facility staff on cleansing techniques.
- The Regional Nurse would review the Infection Control portal to ensure that infections were care planned and appropriate precautions were implemented.
- A root cause analysis would be completed by the Governing Body and brought to the facility QAPI committee for review.
- The facility Executive Director was responsible for ensuring on-going compliance with the plan.
- Other residents in the facility with orders for transmission-based precautions were reviewed to validate they were placed on appropriate transmission-based precautions.
- Residents admitted to the facility were to be reviewed to validate that transmission-based precautions were implemented as appropriate, and PPE was available in the facility.
- Findings of the above audits would be reviewed with the medical director.
Verbal Abuse Incidents in LTC Facility
Penalty
Summary
The facility failed to protect residents from verbal abuse by staff, as evidenced by incidents involving two residents. Resident 18, who was admitted with anxiety and depression, experienced an incident where a former agency CNA, Staff 38, refused to get assistance while helping the resident off a bedpan, resulting in a spill. Despite Resident 18's repeated requests for help, Staff 38 continued to clean the resident while making inappropriate comments, leaving the resident feeling stripped of dignity. The care plan for Resident 18 indicated a need for two-person assistance with bed mobility, which was not followed, leading to the incident. In another incident, Resident 1, who has cerebral palsy and is cognitively intact, reported a grievance after a confrontation with Staff 22, the Kitchen Manager. During a discussion about a meal that Resident 1 believed caused diarrhea, Staff 22 became defensive, raised his voice, and made aggressive comments. Witnesses, including other residents and staff, confirmed that Staff 22's behavior was inappropriate and could be considered verbal abuse. The incident was initially not recognized as abuse, but further discussions in a Resident Council meeting led to an investigation. Both incidents highlight a failure to adhere to expected standards of care and communication, resulting in residents feeling unsafe and disrespected. The facility did not place Resident 18 on alert for psychosocial harm following the incident, and there was a delay in recognizing the verbal abuse experienced by Resident 1. These deficiencies indicate a lack of appropriate response to allegations of abuse and a failure to protect residents from harm.
Failure to Document and Follow Up on Advance Directives
Penalty
Summary
The facility failed to obtain and document advance directives for four out of five sampled residents, which placed them at risk of not having their healthcare decisions honored. Resident 8 was admitted with a leg fracture and was noted to have a POLST that was not signed by a physician, and there was no advance directive in the electronic record despite indications otherwise. Resident 30, admitted with an open wound, was supposed to receive an advance directive booklet, but there was no documentation of this in the progress notes. Similarly, Resident 32, admitted with malnutrition, was expected to have an advance directive brought by a family member, but there was no documentation of this occurring. Resident 20, who was cognitively intact with a BIMS score of 15, had no advance directive documented in their medical record despite multiple care conferences over the course of a year. The Social Services Director, Staff 24, stated that advance directives were reviewed during care conferences, and packets were provided, but there was no follow-up on whether the directives were completed or documented. This lack of follow-up and documentation was consistent across the cases reviewed, indicating a systemic issue in the facility's handling of advance directives.
Failure to Provide Homelike Dining Environment
Penalty
Summary
The facility failed to provide a homelike dining environment in three dining rooms, as observed during a survey. In the Middle dining room, meals were left on delivery trays during the meal, and tables lacked decorations and tablecloths. In the Back dining room, meals were also left on trays, and no tablecloths were present. Similarly, in the Front dining room, meals were left on trays. The facility's administrator acknowledged that meals should feel like home and that trays and plate warmers should be removed unless requested by residents.
Medication and Wound Care Deficiencies
Penalty
Summary
The facility staff failed to adhere to professional standards of practice for medication administration and wound care, affecting four residents. For Resident 9, the LPN administered Losartan late and without checking the resident's blood pressure, despite standing orders to hold the medication if the systolic blood pressure was below 100. The LPN admitted to not receiving guidance on handling late medication administration and acknowledged the oversight. Resident 10, who had a Stage 4 pressure ulcer, received inadequate wound care from the Resident Care Manager. The staff member did not sanitize hands before donning gloves, used contaminated surfaces for clean supplies, and failed to change gloves between handling soiled and clean items. The Regional Nurse confirmed that the staff member had recently completed a wound care class and should have known the correct procedures. For Resident 19, the LPN handled medications with unsanitized hands and did not follow the physician's order to have the resident rinse their mouth after using a Combivent inhaler. Additionally, the LPN relied on outdated blood pressure readings before administering Metoprolol, contrary to the facility's standing orders. Resident 33's medications were administered late, and the LPN did not check blood pressure before giving blood pressure medications. Furthermore, Levothyroxine was given after breakfast, contrary to guidelines that it should be taken on an empty stomach.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in an 18.92 percent error rate. This was due to seven errors out of 37 medication administration opportunities. One incident involved a resident with heart disease who was administered medications one hour and 45 minutes late without a blood pressure check, despite standing orders to hold blood pressure medications if systolic pressure was less than 100. The LPN involved did not receive guidance from management on procedures for running late with medication administration. Another incident involved a resident with respiratory failure, where an LPN failed to sanitize her hands or wear gloves before handling medications and did not ensure the resident rinsed their mouth after using a Combivent inhaler, as per physician orders. Additionally, a resident with heart disease and thyroid disorder received medications late, after breakfast, without a blood pressure check, and contrary to instructions for Levothyroxine to be taken on an empty stomach. The LPN involved was not informed about procedures for late medication administration.
Failure to Provide Appropriate Call Light System for Resident
Penalty
Summary
The facility failed to assess and provide an appropriate call light system for a resident with Parkinson's disease and hand contractures, who was unable to use the button call light. The resident was admitted in February 2020 and had a care plan revised in November 2024, which included the use of a push pad call light within reach due to hand contractures. However, observations on multiple occasions revealed that the resident was unable to use the push pad call light and had to yell for assistance, indicating unmet needs for hydration as the resident expressed thirst and frustration. Staff interviews confirmed that the resident's care needs had increased, and the care plan did not address the resident's inability to use the call light or the need for frequent fluid offers. The Resident Care Manager acknowledged that the resident was not assessed before implementing the new push pad call light, and the care plan lacked necessary interventions to address the resident's fluid and call light needs. This oversight placed the resident at risk for unmet needs and lack of ability to call for assistance.
Inaccurate Assessment of Resident's Discharge Preferences
Penalty
Summary
The facility failed to accurately assess a resident's desire for discharge, leading to a deficiency in the assessment process. The resident, admitted in September 2020 with a diagnosis of bipolar disorder, was documented in the 9/28/24 Annual MDS as not wanting to discuss leaving the facility or returning to the community. However, interviews conducted on 11/4/24, 11/5/24, and 11/6/24 revealed that the resident expressed a desire to discharge to a home in Corvallis or Philomath. Staff members, including the Social Service Manager and Social Service Assistant, confirmed the resident's wish to leave the facility, acknowledging that the information on the 9/28/24 Annual MDS was incorrect. The Regional Nurse also acknowledged the error and indicated that corrections were being made to the MDS.
Failure to Conduct Required Mental Health Evaluations
Penalty
Summary
The facility failed to ensure that a resident with a serious mental illness received the necessary evaluations and care. The resident, admitted in September 2020, had a diagnosis of bipolar disorder. A PASRR Level 1 form dated September 17, 2024, indicated that the resident exhibited serious mental illness indicators and required further evaluation at the nursing facility. However, as acknowledged by the Social Service Manager on November 6, 2024, no further evaluations for mental illness were completed for the resident, leading to a deficiency in meeting the resident's mental health needs.
Failure to Provide Scheduled Spiritual Activities
Penalty
Summary
The facility failed to provide activities of choice for a resident, specifically Catholic communion, which was not received since the beginning of 2024. The resident, admitted in February 2022 with diagnoses including anxiety and depression, was cognitively intact as per a July 2024 Quarterly MDS. Despite Catholic communion being scheduled for November 5, 2024, the resident reported not receiving it. The Activities Director confirmed that no one was able to come in for communion on that date due to a COVID outbreak in the facility and also stated that documentation of when residents received communion was not maintained. The resident's participation in spiritual activities was minimal, with only one recorded instance from August to November 2024.
Failure to Follow Insulin Administration Orders
Penalty
Summary
The facility failed to adhere to physician orders for insulin administration for a resident with diabetes, leading to a deficiency. The resident, admitted in November 2021, had a physician order dated October 2024 for 13 units of Humalog insulin before each meal, with instructions to hold the medication if the capillary blood glucose (CBG) level was less than 100. However, on November 1 and November 6, 2024, the resident's CBG levels were 123 and 110, respectively, and the insulin was incorrectly held by an LPN. The LPN mistakenly believed there were standing orders to hold insulin if the CBG level was at 150 or above and did not seek clarification from the resident's physician. This oversight was acknowledged by the Regional Nurse, who confirmed that physician orders should be followed as written.
Deficiencies in Pressure Ulcer Care and Infection Control
Penalty
Summary
The facility failed to properly assess and treat pressure ulcers for two residents, leading to deficiencies in care. Resident 8, admitted with a leg fracture, developed blisters on the left thigh due to a leg brace. These blisters were not accurately documented as Stage 2 pressure ulcers, as per CDC guidelines, and the incident report was incomplete, lacking input from the CNA who identified the condition. The wound nurse assessed the situation, but the documentation and classification of the blisters were not thorough or accurate. Resident 10, admitted with a Stage 4 pressure ulcer, was at high risk for developing additional ulcers due to factors like malnutrition and incontinence. During a wound care procedure, an LPN failed to maintain proper infection control practices. The LPN did not sanitize hands before donning gloves, used soiled gloves and scissors to handle clean dressings, and did not establish a clean field for the supplies. These actions compromised the sterility of the wound care process, as acknowledged by the LPN and a regional nurse.
Failure to Address Accident Hazards for Residents
Penalty
Summary
The facility failed to maintain an environment free from accident hazards for two residents, leading to potential risks of injury. Resident 17, who was admitted with diagnoses including depression and severe obesity, exhibited hoarding behaviors that were not addressed in a timely manner. On October 27, 2024, Resident 17's bedside table fell on their left shin, causing a small abrasion. Despite an investigation by the Director of Nursing Services (DNS) on October 28, 2024, no predisposing environmental factors were identified, and the table was not evaluated until November 5, 2024. The hoarding issue was only acknowledged on November 7, 2024, indicating a delay in addressing the environmental hazard. Resident 37, admitted with chronic heart failure and dementia, had a care plan dated August 15, 2024, which required fall mats on both sides of their bed. However, observations from November 4 to November 8, 2024, revealed the absence of these fall mats. During an interview on November 8, 2024, the Resident Care Manager (LPN) was unaware of the missing fall mats, despite the care plan's requirements. This oversight in implementing the care plan further contributed to the unsafe environment for Resident 37.
Failure to Document Catheter Care
Penalty
Summary
The facility failed to provide adequate care and services related to catheterization for a resident who was reviewed for catheterization. The resident, who was admitted with a diagnosis including a Stage 4 pressure ulcer, was observed with blood in the catheter tubing. The resident mentioned that blood in the tubing was normal after a catheter change. However, a review of the Treatment Administration Record (TAR) and Nursing Progress Notes for November 2024 revealed no documentation of catheter care, such as flushing, cleaning, or changing the catheter. Additionally, a staff member, identified as the Resident Care Manager-LPN, confirmed that there was no documentation in the resident's electronic record indicating that catheter care was provided.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for two residents, leading to potential risks of respiratory infections. Resident 17, who was admitted with diagnoses including depression and sleep apnea, used a CPAP machine. The facility's policy on equipment sanitation did not specify proper storage for respiratory equipment. Despite a physician's order to clean the CPAP equipment weekly, observations revealed that Resident 17's CPAP mask was improperly stored on a counter with a used tissue nearby. Staff confirmed that the CPAP equipment was stored uncovered with other personal items, acknowledging the inadequacy of the facility's policy and the improper storage practice. Similarly, Resident 28, admitted with respiratory failure and using a BiPAP machine, was observed to have their equipment stored unsanitarily on multiple occasions. The BiPAP machine was found on top of the nightstand, hanging over it, and on the bedrail, all in an unsanitary manner. Staff confirmed the improper storage of the BiPAP mask, which should have been stored in a bag. These observations highlight the facility's failure to ensure proper storage and sanitation of respiratory equipment, as required by their policies and physician orders.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by an incident involving a resident with cerebral palsy who was dependent on staff for toileting. The resident, who was cognitively intact and able to understand others, reported that two caregivers made derogatory comments about the smell of their feces while providing toileting assistance. This incident was not documented in the resident's progress notes, indicating a lack of proper record-keeping regarding the event. The resident expressed embarrassment and reported the incident to the Activities Director, who then informed the facility administrator. The administrator confirmed awareness of the allegation and stated that the contract of the involved agency CNA was terminated due to the inappropriate comment. Despite the CNA's denial of making such comments, other staff members corroborated the resident's account, noting that the resident felt shamed and embarrassed. The incident highlights a failure in maintaining the dignity and respect of the resident, as required by regulatory standards.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to timely report an allegation of abuse to the State Survey Agency (SSA) for a resident who was admitted with diagnoses including anxiety and depression. The incident occurred on August 31, 2024, which was a Saturday, and the following Monday was a holiday. The Facility Reported Incident (FRI) was sent to the SSA on Tuesday, September 3, 2024. During interviews, the Administrator was unable to recall when the FRI was sent, and the Director of Nursing Services (DNS) confirmed the timeline of events. This delay in reporting placed residents at risk for abuse.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 119 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Albany
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Timberline Post Acute | 0.8 mi | ★★★★★ | 8 | 0 |
| Mennonite Home | 2.6 mi | ★★★★★ | 8 | 0 |
| Corvallis Manor Nursing & Rehabilitation Center | 7.1 mi | — | 20 | 0 |
| Avamere Rehabilitation Of Lebanon | 10.8 mi | ★★★★★ | 28 | 0 |
| Lebanon Veterans Home | 11 mi | ★★★★★ | 17 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.