Umpqua Valley Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Roseburg, Oregon.
- Location
- 525 W. Umpqua Street, Roseburg, Oregon 97471
- CMS Provider Number
- 385143
- Inspections on file
- 21
- Latest survey
- August 26, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Umpqua Valley Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A facility failed to maintain a safe and homelike environment when air conditioning units in two hallways leaked water for an extended period, damaging walls and personal items, despite repeated reports from CNAs and residents. Additionally, two resident rooms had broken bathroom pocket doors replaced with shower curtains, leading to concerns about privacy and odor control. Maintenance staff were aware of these issues, but monthly audits were not conducted, and repairs were delayed.
The facility failed to consistently monitor residents for adverse side effects to anticoagulant medications, placing them at risk. One resident with atrial fibrillation was monitored sporadically, another with peripheral vascular disease was not monitored 31 out of 46 times, and a third resident post-stroke was monitored only 11 out of 60 times in one month.
The facility failed to implement Enhanced Barrier Precautions (EBP) in a timely manner for four residents, placing them at risk for cross-contamination. Residents with wound infections, cellulitis, and nephrostomy tubes were not placed on EBP promptly, despite the requirement being effective from 4/1/24. Staff acknowledged delays in educating and implementing the EBP process.
The facility failed to provide sufficient staffing, leading to unmet needs for a resident with a stroke diagnosis who required extensive assistance with toileting. Multiple instances of inadequate staffing, long call light wait times, and incontinent episodes were documented. Staff confirmed being overwhelmed and unable to complete all required care, placing residents at risk.
The facility failed to complete annual performance reviews for five CNAs, as their performance evaluations were not found in their records. This deficiency was acknowledged by the Administrator during an interview and record review.
The facility failed to post accurate and complete staffing information, with multiple instances of missing staff hours and resident census data on the Direct Care Staff Daily Reports (DCSDR). The administrator and DNS were notified, but no additional information was provided.
The facility failed to consistently monitor residents on psychotropic medications, leading to incomplete documentation and potential overmedication. Multiple residents exhibited behaviors and side effects that were not properly documented or monitored, and consents for medication use were not always obtained.
The facility failed to ensure proper antibiotic stewardship for three residents. One resident was prescribed an ineffective antibiotic, another continued antibiotics despite a negative culture, and a third received antibiotics without the necessary diagnostic tests. Staff acknowledged these oversights.
A resident with depression and seizures was moved from a private to a semi-private room despite refusing the transfer. The facility repurposed the room for a new hospice admission, and staff were unaware of the regulatory requirements regarding the resident's right to refuse the transfer.
The facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) for a resident admitted with cellulitis and discharged after completing IV antibiotics. The Social Service Director confirmed that the NOMNC was not issued prior to discharge.
A resident reported missing a black jacket and a shrinker sock, but the facility failed to log and address the grievance properly. The laundry and social services staff were unaware of the missing items, indicating a breakdown in the facility's grievance resolution process.
The facility failed to provide a resident with an activity program, despite documented preferences for 1:1 visits, magazines, music, and family interactions. The resident's clinical record showed no activities provided for a month, and observations confirmed the resident was often in bed with no music or television on and magazines out of reach. The Activity Director acknowledged the lack of activities and the need for staff assistance.
A resident with COPD and chronic pain was found noncompliant with the facility's smoking policy by keeping and charging electronic vaping materials in their room. The CNA observed the noncompliance but did not fully address it, and the LPN Unit Manager was not informed. This oversight placed residents at risk for a hazardous environment.
A resident experienced a 9.21% weight loss, and the facility failed to timely evaluate and re-weigh the resident to verify the accuracy of the recorded weight. The clinical record lacked an assessment or rationale for the weight loss, and an LPN acknowledged the oversight.
The facility failed to consistently monitor a dialysis access site for a resident with end-stage renal disease. Despite an order to check the site for bruit and thrill twice a day, records showed significant lapses in monitoring. An LPN confirmed the expected procedures but could not explain the lack of adherence.
The facility failed to ensure pneumonia vaccines were offered to two residents with heart disease, placing them at risk for respiratory illness. Both residents had received two pneumonia vaccines but were not assessed by their physicians for an additional vaccine despite being eligible.
The facility failed to inform two residents or their representatives about the risks and benefits of prescribed medications, leading to a lack of informed consent. One resident's family member confirmed they did not receive any information, and staff admitted that no consents were completed as required.
The facility failed to report allegations of abuse and misappropriation for two residents. One resident reported missing money, which was not reported to authorities, and another resident was hit by a fellow resident, with the incident reported late.
The facility failed to thoroughly investigate allegations of abuse involving two residents. One resident reported missing money, which was replaced without an investigation. Another resident was hit by a cognitively impaired resident, but the investigation lacked witness statements and accurate evaluations.
A facility failed to ensure a safe and orderly discharge for a resident with a stroke diagnosis, resulting in delays in obtaining essential medications. The LPN responsible for the discharge was not provided with proper directions or a checklist, leading to incomplete documentation and communication with the pharmacy.
The facility failed to respond to changes in condition and follow physician orders for three residents. One resident experienced unmanaged pain and hematuria without appropriate follow-up, another missed doses of Cozaar without physician notification, and a third did not receive a lipid panel or proper vital sign monitoring as ordered.
The facility failed to provide appropriate foot care for a diabetic resident. Despite the care plan's interventions, there was no documentation of referrals to a podiatrist or foot care nurse, and no nail care was documented for extended periods. A public complaint revealed the resident's toenails were growing into their toes, causing pain, which was confirmed by a witness and the DNS.
The facility failed to provide adequate pain management for three residents, leading to a lack of pain control. One resident's pain presence was not documented 33 out of 50 times, another resident's pain quality and location were not documented before administering Tramadol, and a third resident's CT scan was not ordered due to staff oversight.
The facility failed to provide annual abuse training for three CNAs, as revealed by a review of in-service records. The Administrator acknowledged the lack of documentation for the required training.
Deficient Physical Environment Due to Leaking AC Units and Broken Bathroom Doors
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in two of five hallways reviewed, specifically regarding malfunctioning air conditioning units and non-operational bathroom doors in resident rooms. Observations revealed that an air conditioning unit in one room was leaking water along the bottom panel, causing water to drip onto a bedside table and down the wall, resulting in damage to the wall panel and personal items. Staff interviews indicated that the leak had been ongoing for several weeks to the entire summer, with multiple reports made to nursing and maintenance staff. Despite these reports, the maintenance department did not conduct monthly audits and relied on housekeeping and nursing staff to report issues. The Maintenance Director acknowledged awareness of the leak, attributing it to ice formation on the coils when the temperature was set too low, which would then melt and cause water to drip when the unit was turned off. Additionally, during a Resident Council meeting, it was reported that the pocket doors for the bathrooms in two rooms were broken and had been replaced with shower curtains. Residents expressed concerns about lack of privacy, inadequate odor control, and potential fire safety risks due to the absence of proper doors. The Maintenance Director confirmed that the pocket doors were broken and that replacement parts were no longer available, resulting in the use of shower curtains as a temporary solution. The Administrator acknowledged the ongoing issues with both the air conditioning units and the bathroom doors.
Failure to Monitor Adverse Side Effects of Anticoagulant Medications
Penalty
Summary
The facility failed to consistently monitor residents for adverse side effects to anticoagulant medications, placing them at risk for adverse reactions. Resident 18, admitted with atrial fibrillation, had an order to monitor for side effects of Eliquis twice a day. However, documentation showed that this monitoring was completed only 11 out of 60 times in April 2024 and once out of 30 times in May 2024. Staff 10 acknowledged the sporadic documentation and incomplete monitoring for Resident 18. Resident 32, admitted with peripheral vascular disease, had an order to take warfarin with specific dosing instructions and to be monitored for adverse reactions every day and night shift. Despite this, monitoring was not performed 31 out of 46 times in April 2024. Staff 10 confirmed the lack of consistent monitoring. Similarly, Resident 52, admitted after a stroke, had an order to monitor for side effects of an anticoagulant medication on day and night shifts. The clinical record indicated monitoring was done only 11 out of 60 times in April 2024 and 2 out of 16 times in May 2024. Staff 2 and Staff 29 confirmed the expectation for documentation each shift, which was not met.
Failure to Implement Enhanced Barrier Precautions Timely
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) in a timely manner for four residents, placing them at risk for cross-contamination. Resident 6, admitted with a wound infection, was not started on EBP until 5/2/24, despite the requirement being effective from 4/1/24. Staff acknowledged that the facility did not educate and implement the EBP process until the end of April 2024. Similarly, Resident 32, admitted with a nephrostomy tube, was not placed on EBP until 5/2/24. Staff confirmed that all new residents were supposed to be reviewed for EBP needs prior to admission, but this was not done promptly for these residents. Resident 9, admitted with cellulitis and a history of MRSA, had open areas with yellow drainage but was not identified for EBP on 5/16/24. Staff acknowledged that the resident should have been placed on EBP due to the drainage and history of MRSA. Resident 127, admitted with a surgical wound infection and receiving medications through a surgically placed catheter, was not placed on EBP until 5/6/24. Staff confirmed that the facility did not implement the EBP process until the end of April 2024, leading to delays in EBP for these residents.
Facility Fails to Provide Sufficient Staffing, Leading to Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of residents, specifically Resident 77, who was admitted with a diagnosis of stroke and required extensive two-person assistance with toileting. The resident's care plan indicated the need for a bladder retraining program and assistance with activities of daily living (ADLs). However, multiple instances of inadequate staffing were documented, including long call light wait times and insufficient CNA coverage, leading to incontinent episodes for Resident 77. The facility did not meet state minimum CNA staffing requirements for 97 out of 366 shifts during the reviewed periods, and complaints about long call light wait times were noted in Council Minutes and a public complaint received on 2/1/24. Interviews with staff confirmed the staffing issues, with CNAs and LPNs reporting being overwhelmed and unable to complete all required care and services for residents. Staff mentioned that residents had to wait over 30 minutes for call lights to be answered, leading to incontinent episodes and unmet needs. The facility's administrator and DNS were informed of these staffing concerns, but no additional information was provided to address the issues. The deficiency placed residents at risk for unmet needs and compromised their care quality.
Failure to Complete Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to ensure that annual performance reviews were completed for five Certified Nursing Assistants (CNAs) who were sampled for staffing. Specifically, the performance evaluations for Staff 24, Staff 25, Staff 26, Staff 27, and Staff 28 were not found in their records. Staff 24 was hired on 3/9/22, Staff 25 on 1/2/18, Staff 26 on 1/25/17, Staff 27 on 3/23/18, and Staff 28 on 5/13/20. This deficiency was acknowledged by the Administrator on 5/14/24 during an interview and record review.
Failure to Post Accurate Staffing Information
Penalty
Summary
The facility failed to post accurate and complete staffing information, as evidenced by multiple instances of missing staff hours and resident census data on the Direct Care Staff Daily Reports (DCSDR). Specifically, from 6/15/23 through 7/15/23, 9/1/23 through 9/15/23, and 11/1/23 through 11/15/23, there were several days where staff hours for CNAs on various shifts were not listed. Additionally, on 5/13/24, the DCSDR was observed with no day shift resident census posted, and later in the day, it was not updated to include evening shift information. On 5/15/24, the DCSDR was posted without the resident census for both day and evening shifts. The facility's administrator and DNS were notified of these incomplete postings on 5/17/24, but no additional information was provided.
Failure to Monitor Psychotropic Medications
Penalty
Summary
The facility failed to consistently and thoroughly monitor residents on psychotropic medications, placing them at risk for receiving unnecessary medications. Resident 4, admitted with diagnoses including depression and psychosis, was prescribed quetiapine and Zoloft. Despite orders to monitor for behaviors and side effects, no documentation was found for these, even though the resident exhibited behaviors such as yelling and hallucinations. Staff acknowledged the lack of proper documentation and monitoring for this resident's medication side effects and behaviors. Resident 18, admitted with depression and insomnia, had orders for trazodone and citalopram. The facility's records showed sporadic and incomplete documentation of monitoring for adverse side effects. The MARs revealed that monitoring tasks were signed as completed only a fraction of the required times, indicating a significant lapse in the monitoring process. Staff confirmed the inconsistency in documentation and monitoring for this resident. Resident 52, admitted with a stroke, was on antidepressant and antianxiety medications and exhibited aggressive behaviors. The facility's records showed that monitoring for side effects and behaviors was infrequent and incomplete. Additionally, there was no consent for the use of Buspar in the clinical record. Staff admitted to not discussing the medication with the resident's decision-maker. Similarly, Resident 77, also admitted with a stroke, was on multiple psychotropic medications. The facility failed to reassess the resident's medication use after treating a UTI and did not consistently monitor for adverse reactions. Staff confirmed the lack of required monitoring for this resident as well.
Failure to Ensure Proper Antibiotic Stewardship
Penalty
Summary
The facility failed to ensure proper antibiotic stewardship for three residents. Resident 1, admitted with bladder cancer, was prescribed Augmentin for 21 days despite a urine analysis revealing pseudomonas aeruginosa, which is not sensitive to Augmentin. There was no documentation of a urologist's review of the urine analysis or an antibiotic time-out. Staff acknowledged the oversight and the inappropriate use of Augmentin for the identified bacteria. Resident 32, admitted with kidney stones, was started on antibiotics for a possible UTI. Despite a urine culture showing no growth, the antibiotics were continued without physician reassessment. Staff acknowledged that the negative culture results should have prompted a review of the antibiotic use. Resident 77, admitted with a stroke, exhibited symptoms suggesting a UTI but did not receive the ordered urinalysis or bladder scan. Despite the absence of these diagnostic tests, the resident was administered Ciprofloxacin for seven days. Staff acknowledged the lack of documentation and failure to perform the necessary tests.
Failure to Honor Resident's Right to Refuse Room Transfer
Penalty
Summary
The facility failed to honor a resident's right to refuse a transfer to another room. Resident 25, who was admitted in 2023 with diagnoses including depression and seizures, was asked to move from a private room to a semi-private room. The resident refused to sign the room change notification on 4/3/24. Despite multiple vacant rooms being available, the resident was moved to a different room on 4/25/24. The resident expressed that they did not want to move and believed they had the right to remain in their room. Staff 5 (Social Services) acknowledged the notification was given because the facility wanted to repurpose the private room for a new hospice admission. Staff 1 (Administrator) and Staff 2 (DNS) stated the transfer was for the benefit of the facility and community, and Staff 1 admitted to being unaware of the regulatory requirements regarding the resident's right to refuse the transfer.
Failure to Issue Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) for one of the sampled residents reviewed for beneficiary notification. Resident 378 was admitted to the facility with Medicare Part A services on 12/1/23 with diagnoses including cellulitis of the right lower limb. A Social Services Note on 1/12/24 indicated that home health services were arranged, and the resident was ready for discharge once IV antibiotics were completed. The IV antibiotics were completed on 1/17/24, and the resident was discharged on 1/19/24. However, a medical record review on 5/14/24 revealed no evidence that a NOMNC was issued to Resident 378. This was confirmed by the Social Service Director, who acknowledged that the resident was not issued a NOMNC prior to discharge.
Failure to Resolve Resident's Report of Missing Clothing
Penalty
Summary
The facility failed to resolve a resident's report of missing clothing, specifically a black jacket and a shrinker sock, for a resident who was cognitively intact and admitted with a surgical infection. The resident reported the missing items to the laundry staff over a week prior, but the items were not logged on the chalkboard or any paper to alert staff to look for them. The laundry staff was unaware of the missing items, indicating a failure in the facility's process for tracking and resolving such grievances. Further investigation revealed that the social services staff was also unaware of the current missing items, although a shrinker sock had been replaced for the resident in the previous year. The facility's grievance policy, which includes addressing grievances in daily staff meetings and resolving them within seven days, was not followed. This lack of proper documentation and communication placed residents at risk for unresolved grievances and missing personal property.
Failure to Provide Activity Program for Resident
Penalty
Summary
The facility failed to ensure a resident was provided an activity program, which placed the resident at risk for decreased quality of life. Resident 63, who was admitted in 2023 with a diagnosis of chronic kidney disease, expressed a preference for 1:1 visits, magazines, music, and family interactions. Despite these preferences being documented in the resident's care plan and activity assessments, the resident's clinical record revealed no activities were provided from mid-April to mid-May 2024. Observations during this period showed the resident often in bed with no music or television on, and magazines out of reach. The resident reported feeling bored and preferred not to be alone, but staff did not consistently provide the requested activities or ensure the resident's preferences were met. The Activity Director confirmed that the resident did not attend any activities during this period and acknowledged the need for staff assistance to provide the requested activities and ensure they were accessible to the resident.
Failure to Enforce Smoking Policy and Prevent Hazards
Penalty
Summary
The facility failed to ensure a resident's environment remained free from smoking hazards for a resident with COPD and chronic pain. The facility's policy required independent smokers to store smoking materials in an individual storage box outside their room. Despite this, the resident was found to be noncompliant with the policy, as they kept electronic vaping cartridges in a bag around their neck and charged an electronic vaping cartridge on their nightstand. This noncompliance was observed by a CNA, who removed the bag but left the charging cartridge in the room. The LPN Unit Manager was not informed of the resident's noncompliance on the day it was observed. The LPN acknowledged that the electronic vaping cartridge should not have been charged in the resident's room. This oversight placed residents at risk for a hazardous environment, as the facility did not adequately enforce its smoking policy or ensure proper supervision to prevent such hazards.
Failure to Timely Evaluate Significant Weight Loss
Penalty
Summary
The facility failed to ensure a resident was evaluated timely after experiencing significant weight loss. Resident 127, admitted in April 2024 with a surgical infection, was noted to have a 9.21% weight loss from 239 pounds on April 29, 2024, to 217 pounds on May 7, 2024. Despite this significant weight change, the resident's clinical record did not contain an assessment, re-weigh, or rationale for the weight loss. Staff 3, an LPN Resident Care Manager, acknowledged that the resident was not re-weighed to verify the accuracy of the recorded weight. On May 11, 2024, the resident's weight was inaccurately recorded as 332 pounds, which was later corrected to 232 pounds on May 12, 2024. However, no additional weight data between May 7, 2024, and May 11, 2024, was provided to verify the initial weight loss.
Failure to Consistently Monitor Dialysis Access Site
Penalty
Summary
The facility failed to consistently monitor a dialysis access site for a resident with end-stage renal disease. The resident, admitted in 2020, had an order dated 3/12/24 instructing staff to monitor the dialysis access site for bruit (whooshing) and thrill (vibration) twice a day. A review of the clinical record revealed that the site was monitored for bruit and thrill only 11 out of 39 opportunities in March 2024, 14 out of 60 opportunities in April 2024, and once out of 32 opportunities in May 2024. When questioned, the LPN Unit Manager confirmed that staff were expected to check the site for any bleeding, bruit, and thrill, and to ensure there was a dressing in place but could not provide additional information regarding the lack of site monitoring.
Failure to Ensure Pneumonia Vaccines Offered
Penalty
Summary
The facility failed to ensure pneumonia vaccines were offered to two residents, placing them at risk for respiratory illness. Resident 42, admitted in 2021 with heart disease, had received two pneumonia vaccines but was not assessed by the physician for an additional vaccine despite being eligible. Similarly, Resident 67, admitted in 2024 with heart disease, also received two pneumonia vaccines but was not evaluated for an additional vaccine. Staff 3 acknowledged the oversight but did not provide documentation of physician evaluation for either resident.
Failure to Provide Medication-Related Risk and Benefits Information
Penalty
Summary
The facility failed to provide medication-related risk and benefits information to residents or their representatives prior to administration for two residents. Resident 77, who was admitted with a diagnosis of stroke, had multiple medications prescribed, including Ativan, Escitalopram, Buspirone, and Seroquel. There was no documentation in the clinical records indicating that the risks and benefits of these medications were communicated to Resident 77 or their representative. A family member confirmed that they did not receive any information about these medications. Additionally, a staff member confirmed that no consents were completed for these medications, despite it being an expected procedure before administration. Similarly, Resident 52, also admitted with a diagnosis of stroke, was prescribed Buspar. The clinical record revealed no information indicating that Resident 52 was notified of the new medication and its risks and benefits. There was no indication that Resident 52 had a surrogate decision maker. A staff member admitted that they did not discuss the medication with Resident 52's son and assumed the son could sign the consent. This lack of communication and documentation placed residents and their representatives at risk for lack of informed consent.
Failure to Report Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to report allegations of abuse and misappropriation to the state agency or local law enforcement for two residents. Resident 1, who was admitted with quadriplegia and was cognitively intact, reported $160 missing on 2/15/24. The facility replaced the money on 3/21/24, but the administrator did not believe the money was missing and did not report the incident to the state agency or local law enforcement. The administrator acknowledged that the allegation was not reported and stated that only a trend of missing money would have been reported. Resident 47, who was admitted with severe cognitive impairment, was hit in the face by Resident 52, who had a stroke and was sitting near the nursing station. The incident occurred on 5/4/24, and an investigation concluded on 5/9/24 found no abuse as Resident 52 was not injured and Resident 47 did not recall the event. The administrator acknowledged that the altercation was reported late on 5/16/24 and additional education was needed.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to complete thorough investigations for allegations of abuse involving two residents. Resident 1, who was admitted with quadriplegia, reported $160 missing on 2/15/24. The facility replaced the money on 3/21/24, but the Administrator acknowledged that no investigation was conducted into the missing money. Resident 1 was cognitively intact at the time of the incident, as indicated by an MDS review on 4/22/24. In another incident, Resident 52, who had a stroke and was cognitively impaired, hit Resident 47 in the face while both were in their wheelchairs near the nursing station. The facility's investigation into the 5/4/24 incident was incomplete, lacking witness statements, accurate cognitive evaluations, and statements from the involved residents. The investigation ruled out abuse and neglect based on the lack of injury and Resident 47's lack of recall, despite Resident 52's admission of hitting Resident 47 on purpose. The Regional Director of Clinical confirmed the absence of additional witness information.
Failure to Ensure Safe and Orderly Discharge
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident who was admitted with a diagnosis of stroke. The discharge packet included instructions for the resident to continue medication on the Discharge Medication List, and the medications were sent to the pharmacy of choice. However, there was no documentation in the resident's clinical record indicating which medications were sent with the resident at the time of discharge or if the pharmacy was provided the prescriptions by the facility. A public complaint revealed that the resident did not receive insulin and other medications upon discharge, and it took two days to get the insulin and approximately three weeks to obtain all the medications. The complainant stated that during a discharge planning meeting, she was informed she would receive 30 days of medications and the prescriptions, but on the day of discharge, an LPN incorrectly informed her that the resident was not on insulin. The pharmacy received a typed list of medications instead of prescriptions, causing delays in obtaining the necessary medications for the resident. Staff interviews revealed that the LPN responsible for the discharge did not complete many discharges at the facility and was not provided with directions, policy, or a checklist on how to discharge a resident. The LPN stated that he went over upcoming appointments and the medications list but did not document which medications were sent with the resident. Another staff member, an LPN Unit Manager, stated that she was notified the day after discharge that the resident did not receive all the medications and called the pharmacy, but she did not document the missing medications or notify the pharmacy in the resident's clinical record. This lack of documentation and communication led to the resident not receiving essential medications in a timely manner, placing the resident at risk for unmet medication needs.
Failure to Follow Physician Orders and Respond to Changes in Condition
Penalty
Summary
The facility failed to respond to changes in condition in a timely manner and did not follow physician orders for three residents. Resident 77, admitted with a stroke diagnosis, experienced significant pain and agitation, but the facility did not effectively manage these symptoms. Despite orders for a urinalysis and medications to address potential UTI and pain, the urinalysis was not completed, and the resident continued to show signs of distress and hematuria without appropriate follow-up. Additionally, there was a significant weight loss and inadequate oral intake that were not adequately addressed by the facility staff. Resident 32, admitted with high blood pressure, had physician orders to administer Cozaar daily. However, the medication was not administered on several occasions when the resident's vitals were outside of parameters, and the physician was not notified of these missed doses. Staff relied on their nursing judgment rather than following the physician's orders or seeking clarification, leading to a lapse in the resident's prescribed treatment. Resident 52, with a history of stroke, had orders to discontinue a heart medication, obtain a lipid panel, and monitor vital signs daily. The lipid panel was not completed, and the change in vital sign monitoring was not implemented as ordered. The resident refused the lab draw once, but staff did not reattempt it, and the necessary changes in monitoring were overlooked. These failures indicate a pattern of non-compliance with physician orders and inadequate response to residents' changing conditions.
Failure to Provide Appropriate Foot Care
Penalty
Summary
The facility failed to provide appropriate foot care for a resident diagnosed with diabetes. The resident's care plan, dated 6/30/23, included interventions such as referring to a podiatrist or foot care nurse and monitoring and documenting foot care needs. However, there was no documentation in the clinical record indicating that the resident was referred to a podiatrist or foot care nurse. Additionally, from 6/18/23 through 11/5/23 and from 11/7/23 through 12/11/23, there was no documentation that the resident received nail care. A public complaint received on 2/1/24 reported that the resident's toenails were growing into their toes, causing pain. This was confirmed by a witness on 5/13/24. The Director of Nursing Services (DNS) also confirmed the lack of documentation related to nail care for the resident's feet on 5/17/24.
Failure to Provide Adequate Pain Management
Penalty
Summary
The facility failed to provide adequate pain management for three residents, leading to a lack of pain control. Resident 32, admitted with diagnoses including surgical aftercare and disc degeneration, had a care plan that required regular pain evaluations and documentation. However, from 4/6/24 to 4/30/24, the resident's pain presence was not documented 33 out of 50 times, and there was no documentation of pain quality, anatomical location, aggravating factors, or relieving factors before administering PRN Roxicodone on multiple occasions. The resident reported waiting up to an hour and a half for pain medication after it was due. Staff acknowledged the missing monitoring but did not provide additional information to address the issue. Resident 77, admitted with a stroke diagnosis, had a care plan that included monitoring for pain and administering Tramadol PRN. However, from 6/26/23 to 7/31/23, there was no documentation of pain quality, anatomical location, aggravating factors, or relieving factors before administering Tramadol on multiple occasions. A public complaint indicated that the resident was in pain but could not identify the location, and Tramadol administration was reported to have a sedative effect. The Regional Director of Clinical was informed but did not provide additional information. Resident 61, admitted with low back pain, had orders for a lumbar MRI and later a CT scan due to sciatica pain. However, the provider's note regarding the CT scan was not read by the staff, and the scan was not ordered. The resident reported uncontrolled pain and was observed with facial grimacing. Staff acknowledged the oversight but did not take immediate action to address the issue.
Failure to Provide Annual Abuse Training for CNAs
Penalty
Summary
The facility failed to provide annual abuse training for three Certified Nursing Assistants (CNAs), identified as Staff 26, 27, and 28. A review of the facility's in-service records revealed that there was no documentation indicating that these staff members had completed the required annual abuse training. This deficiency was acknowledged by the facility's Administrator during an interview on May 16, 2024.
Latest citations in Oregon
A resident with acute respiratory failure and heart failure had a documented Full Code status and a POLST specifying Attempt Resuscitation/CPR and Full Treatment. During night rounds, two CNAs found the resident not breathing, cool to the touch, with yellow skin and no pulse, but did not initiate CPR or call a code blue, instead going to notify an LPN. The LPN assessed the resident, confirmed absence of vital signs, noted the body was cold with mottling and no rigor mortis, and contacted the DNS, physician, and 911 for the coroner’s number, but did not start CPR or activate a code blue. No lifesaving measures were attempted despite facility policy requiring CPR for unresponsive residents without a valid DNR and the resident’s clearly documented full code status, leading surveyors to cite Immediate Jeopardy and substandard quality of care.
A resident with respiratory failure and pneumonia, who was Full Code and not on hospice, was found during routine rounds and suspected to be deceased. Nursing staff assessed the resident, noted there was no rigor mortis, confirmed death, and did not initiate a code blue or any resuscitation efforts despite the resident’s Full Code status. The facility later treated this as a potential neglect incident but did not report it to the State Agency within the required two-hour timeframe, as confirmed by the regional QA director.
A resident with chronic pain and a left below-knee amputation, who required supervision or touching assistance with ADLs, was discharged after returning from an outing shortly after midnight. Although discharge instructions noted the need for assistance and assistive devices, there was no documentation of referrals for medical equipment or home health services. Facility staff documented that the resident was discharged because they were out past midnight and believed Medicare would not cover the stay, did not issue a NOMNC, and recorded the discharge as voluntary despite the resident later reporting they had been “kicked out” and were sleeping on a friend’s couch with difficulty getting around. Staff interviews revealed no financial issues and indicated the resident had originally been scheduled for discharge at a later date.
A resident with a hip fracture and anxiety reported to social services that a CNA had been rough, told the resident to take themself to the bathroom, and instructed them not to get out of bed until a specified early morning time. The allegation was received by facility staff in the late afternoon, but the incident report was not submitted to the State Agency until the following day, exceeding the required 2-hour reporting timeframe acknowledged by the DNS. The deficiency concerns this untimely reporting of an abuse allegation, despite the CNA’s denial of any abuse.
A resident with hemiplegia, previously evaluated as not appropriate to self-administer any medications, was found to have open tubes of antifungal cream, anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) stored in a bedside drawer. Record review showed there were no MD orders for several of these topical products and no order permitting self-administration. An RN case manager confirmed the absence of orders, and the resident reported self-administering the medications, demonstrating a failure to ensure medications were administered only as ordered and in accordance with the resident’s assessed ability.
A resident with hemiplegia, previously evaluated as not appropriate to self-administer medications, was found with open containers of anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) in a bedside drawer. Record review showed no MD orders, no documented indication for use, and no monitoring for these medications. An RN case manager confirmed there were no orders and that staff did not administer or monitor the creams, while the resident reported self-administering them.
The facility failed to investigate multiple staff-reported allegations that one cognitively intact, wheelchair-using resident engaged in sexually inappropriate behaviors toward three other residents with significant cognitive and neurological impairments. Staff reported finding a resident with a ripped brief, crying and resisting care, and suspected sexual contact; they also reported that the alleged aggressor tried to take another resident into a shower room for sexual acts, attempted to video and kiss that resident, and encouraged a third resident to remove their top while present with a phone. CNAs, social services, and other staff stated they informed the administrator, DNS, HR, and unit management about these incidents and behaviors, but the administrator acknowledged that no investigations were conducted, despite being aware of the reports.
A resident with multiple sclerosis, care planned as dependent on two staff and requiring a Hoyer lift for transfers, was instead transferred by a CNA using a stand-pivot method without the lift or a second staff member. The CNA reported she had not read the resident’s care plan and described performing the transfer by giving the resident a “giant bear hug” and making several attempts to move the resident from chair to bed. The resident reported right flank pain and stated the transfer caused three broken ribs, although an x-ray later showed no rib fractures or dislocation and no visible injury was noted.
A resident with multiple sclerosis was admitted with physician orders for PT and OT, but review of the clinical record showed no documentation that these therapies were ever provided. The resident reported not receiving any therapy since admission, and the Director of Rehabilitation confirmed that no therapy services had been delivered during this period despite active orders, resulting in a failure to provide ordered rehabilitative services.
A dependent resident with dementia and a history of stroke, identified on the MDS as requiring staff assistance for showers, did not consistently receive scheduled bathing, and one CNA falsely documented that bathing had been provided. CNA task reports showed missed or undocumented baths on scheduled days, and an internal investigation confirmed that a bath recorded as completed on one date had not actually occurred. Staff interviews indicated that if bathing was not documented it usually did not occur, and that scheduled bathing was expected to be provided by staff.
Failure to Initiate CPR for a Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide CPR in accordance with a resident’s documented full code status. The facility’s Emergency Procedure CPR policy, initiated in 2001, required staff trained in CPR to initiate resuscitation on unresponsive residents who were not breathing unless there was a valid DNR order or clear signs of irreversible death such as rigor mortis. The policy further specified that if a resident’s DNR status was unclear, CPR should be started and continued until a DNR was confirmed. Resident 3 had been admitted with diagnoses including acute respiratory failure and heart failure and had a care plan and POLST on file indicating Full Code/Attempt Resuscitation and Full Treatment, including use of intubation, advanced airway interventions, mechanical ventilation, and transfer to hospital or ICU if indicated. On the night of the incident, a CNA (Staff 5) documented last vital signs for the resident at approximately 10:45 PM, with oxygen saturation of 92% on one liter of oxygen. At 2:00 AM, the resident was observed sleeping, breathing, and with a dry brief. Around 4:00 AM, Staff 5 and another CNA (Staff 8) entered the resident’s room and observed that the resident was not breathing, had yellow skin color, was cool to the touch, and had no palpable pulse. Both CNAs concluded the resident was deceased and went to notify the LPN (Staff 4) instead of initiating CPR or calling a code blue, despite having recent CPR training and later stating that, in retrospect, they would have started CPR and called for a code blue. When Staff 4 (LPN) entered the room, she assessed the resident and found no pulse, blood pressure, or respirations, noted the body was cold, with some mottling on the lower legs, pale/yellowish skin color, and no rigor mortis. Staff 4 did not initiate a code blue or CPR and instead contacted the DNS (Staff 2) and the physician, and then called 911 to obtain the coroner’s phone number. No lifesaving measures were attempted by any staff, despite the resident’s documented full code status and the facility policy requiring CPR in the absence of a valid DNR or signs of irreversible death. The DNS later stated she expected staff to call a code blue immediately, start CPR, call 911, and verify the resident’s code status. Surveyors determined that the facility failed to provide CPR according to the resident’s code status, placing all residents with full code status at risk and constituting substandard quality of care, with the noncompliance cited as Immediate Jeopardy and Past Noncompliance.
Removal Plan
- Administrator, DNS and nursing staff would be re-educated on the code blue process, how to locate a resident's code status in PCC and the POLST on file, and the importance of following individual resident care plans and orders.
- Resident code status would be cross-referenced with the PCC order, POLST scanned in binder, care plan, and resident dashboard.
- DNS or designee would monitor resident code status preferences for new admissions/returning admissions from hospitalizations.
- DNS or designee would audit code status for all new admissions and readmissions from hospitalization or ED visits, and share audit results with the QAPI committee to ensure substantial compliance is maintained.
- DNS or designee would complete a mock code.
- DNS or designee would complete mock codes.
Failure to Timely Report Alleged Neglect Involving Lack of CPR for Full Code Resident
Penalty
Summary
The facility failed to timely report an allegation of potential neglect related to CPR to the State Agency for one resident. The resident was admitted in February 2026 with diagnoses including respiratory failure and pneumonia and had a Full Code status, was not on hospice, and therefore was to receive CPR if found unresponsive. According to the facility’s investigation dated six days after the resident’s death, staff found the resident during routine rounds and suspected the resident was deceased, notified the nurse, and the nurse confirmed the resident was deceased. The investigation documented that at the time of the nurse’s assessment the resident did not have rigor mortis, yet the nurse did not initiate a code blue or any resuscitation interventions despite the Full Code status. The incident, which occurred on an identified date, was not reported to the State Agency until a later identified date, and the Regional Director of Quality Assurance confirmed that the facility did not report the incident within the required two-hour timeline. This failure to timely report the allegation of potential neglect involving the lack of CPR initiation for a Full Code resident constituted the deficiency identified by surveyors.
Failure to Ensure Safe and Orderly Discharge After Late Return from Outing
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and orderly discharge for a resident who was admitted with chronic pain, a left below-knee amputation, and post-surgical aftercare needs. An admission MDS completed shortly after admission documented that the resident was cognitively intact but required supervision or touching assistance with toileting, transfers, and bathing. Discharge instructions indicated the resident was being discharged home and that the resident’s current physical status required assistance and assistive devices, yet there was no documentation of referrals for needed medical equipment or a home health referral. The facility’s records did not show that these services or equipment were arranged prior to discharge. On the night in question, a nursing note documented that the resident returned to the facility after an outing at 12:23 AM, after the facility had notified the police because the resident’s location was unknown. The resident reported having been out with friends and being unaware of any concern. A social services note stated that because the resident was out past midnight, the resident was discharged from the facility, and a NOMNC was not issued because the resident left prior to the scheduled discharge and on their own initiative. A discharge summary documented that discharge instructions were reviewed with the resident, who refused to sign and was leaving voluntarily, and the voluntary consent form included a handwritten statement that the resident refused to sign. Later, the resident stated they had been “kicked out” for coming back late and were sleeping on a friend’s couch, finding it difficult to get around. Staff interviews showed there were no financial issues documented, that staff believed Medicare would not cover the resident if out past midnight, and that the resident had been scheduled for discharge several days later, while a regional director later characterized the situation as a clerical error and confirmed a normal discharge should have been completed.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to timely report an allegation of abuse to the State Agency after a resident reported that a CNA had been rough and verbally directive with them. The resident, who had been admitted with diagnoses including a hip fracture and anxiety, stated that the CNA was “kind of rough,” told the resident to take themself to the bathroom, and instructed the resident not to get out of bed until 6:00 AM. The resident reported this allegation of abuse involving the CNA to the social services staff member at 4:00 PM on 1/29/26. According to the facility’s investigation documentation, the allegation was received by staff at 4:00 PM on 1/29/26, and the Facility Reported Incident form was not received by the State Agency until 2:13 PM on 1/30/26. The DNS acknowledged that the facility became aware of the allegation at 4:00 PM on 1/29/26 and that it should have been reported to the State Agency within two hours but was not. The CNA denied abusing the resident or any resident, but the deficiency centers on the delay in reporting the allegation to the State Agency within the required timeframe.
Failure to Prevent Unauthorized Self-Administration of Non-Prescribed Medications
Penalty
Summary
Surveyors identified that a resident was self-administering non-prescribed topical medications despite a documented determination that they were not appropriate to self-administer any medications. The resident, admitted with hemiplegia, had a Self-Medication Administration Evaluation dated 11/13/25 indicating they were not appropriate to self-administer medications. During an observation on 3/19/26 at 7:50 AM with a RN case manager, open tubes of antifungal cream, anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) were found in the resident’s bedside table drawer. Review of the clinical record showed there were no physician orders for the anti-itch cream, hydrocortisone cream, or DMSO, and the resident did not have an order to self-administer any medications. The RN case manager confirmed the lack of orders for these medications, and at 8:10 AM the resident stated they did self-administer the medications found in their room. This constituted a failure by the facility to ensure the resident did not self-administer non-prescribed medications and to provide treatment and care according to physician orders and the resident’s evaluated ability to self-administer medications.
Unmonitored Self-Administration of Topical Medications Without Physician Orders
Penalty
Summary
The facility failed to ensure a resident’s drug regimen was free from unnecessary drugs by not providing adequate monitoring, indication for use, or physician orders for multiple medications. A resident admitted with hemiplegia in May 2024 had a self-medication administration evaluation dated 11/13/25 indicating they were not appropriate to self-administer any medications. During an observation on 3/19/26, an RN case manager found an open tube of anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) in the resident’s bedside table drawer. Record review showed no physician orders, no documented indication for use, and no monitoring for these medications. The RN case manager confirmed the resident did not have orders for the anti-itch cream, hydrocortisone cream, or DMSO, and that staff did not administer or monitor these medications. The resident stated they self-administered the medications found in their room, despite the prior evaluation determining they were not appropriate to self-administer any medications.
Failure to Investigate Multiple Allegations of Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to investigate multiple allegations of sexual abuse involving three residents. Resident 102, who had cognitive loss equivalent to a young child, legal blindness, and was non-verbal, was reportedly found with a ripped brief, crying, and resisting a brief change. Staff reported concerns that another resident, Resident 105, had performed or attempted to perform sexual acts on Resident 102. Staff members, including CNAs and social services, stated they informed facility management, including the Administrator and DNS, about the torn brief, Resident 102’s distress, and concerns that Resident 105 was being sexually inappropriate with multiple residents. Despite these reports and discussions in morning meetings, the Administrator acknowledged that no investigation was completed, believing the incident was based on staff assumptions. The facility also failed to investigate allegations involving Resident 103, who had Alzheimer’s disease and Parkinson’s disease. Staff reported that Resident 105 attempted to take Resident 103 into a shower room to perform sexual acts, and that a staff member intervened. The complainant later spoke with Resident 103, who stated that Resident 105 was “sick” and made bad comments. Other staff reported to human resources, the DNS, and the Administrator that Resident 105 attempted to take a resident into a shower room to unclothe the resident, and that Resident 105 attempted to video Resident 103, expressed a desire to kiss Resident 103, and get the resident into a shower room. The Social Service Director confirmed she reported these concerns to the Administrator, who stated he was aware of the incident but that no investigation was completed. A third failure to investigate involved Resident 108, who had Huntington’s disease and dementia. A staff member reported observing Resident 105 telling Resident 108 to take off their shirt and gesturing for them to do so, and stated they completed a written statement and gave it to the unit manager. Another CNA reported hearing that Resident 105 and other residents were laughing and encouraging Resident 108 to remove their top, and also reported observing Resident 105 rubbing other residents’ backs more physically than appropriate. Social services reported being told that Resident 108 was removing their top while Resident 105 was in the dining room with a phone, and that Resident 105 admitted to the behavior but described it as innocent. The Administrator stated he was aware of Resident 108 removing their shirt while Resident 105 was present, yet confirmed that no investigation was completed for this incident. These failures to investigate led surveyors to determine that the facility did not respond appropriately to alleged violations of sexual abuse for the three residents.
Removal Plan
- Residents 102, 103, and 108 received head-to-toe skin assessments completed by RCMs with no observed findings.
- Resident 105 was placed on one-to-one observations pending investigations.
- Staff 1 (Administrator) and Staff 2 (DNS) were re-educated on the facility's abuse policy, reporting, and thorough investigations.
- Social Services will interview all interviewable residents regarding abuse.
- Nurses will complete a head-to-toe assessment on all non-interviewable residents.
- All staff, including agency staff, will be re-educated on the facility's abuse policy and reporting.
Failure to Follow Care-Planned Hoyer Lift Transfer Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow a resident’s care plan interventions for transfers, resulting in a transfer being performed without required equipment and assistance. A resident admitted in February 2026 with multiple sclerosis had a 2/25/26 ADL care plan indicating the resident was dependent on two staff members for transfers and required use of a Hoyer (mechanical) lift. Despite this, on 2/28/26 a CNA (Staff 3) performed a stand-pivot transfer without the Hoyer lift and without a second staff member. The resident later reported that Staff 3 gave a “giant bear hug” and made several attempts to transfer the resident from chair to bed, after which the resident reported right flank pain and stated the transfer caused three broken ribs. An x-ray on 3/10/26 showed no rib fractures or dislocation, and the resident was assessed to have no visible injury. During interview, Staff 3 confirmed she had completed a stand-pivot transfer with the resident and acknowledged she had not read the resident’s care plan, and the Administrator confirmed that the resident had been care planned for a two-person Hoyer lift transfer at the time of the incident.
Failure to Provide Ordered Rehabilitative Services
Penalty
Summary
The facility failed to provide ordered rehabilitative services to a resident with multiple sclerosis. The resident was admitted in February 2026 with admission orders dated 2/24/26 for both physical therapy and occupational therapy. Review of the resident’s clinical record showed no documented evidence that any therapy services were provided as ordered. In an interview on 3/11/26 at 10:58 AM, the resident reported not having received any therapy since admission. During a separate interview on 3/11/26 at 10:40 AM, the Director of Rehabilitation confirmed that the resident had not received any therapy services from the date of admission through 3/11/26, despite the existing orders for physical and occupational therapy. This failure to implement the physician’s orders for rehabilitative services for this resident placed the resident at risk for a decline in range of motion.
Failure to Provide and Accurately Document Scheduled Bathing for a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a dependent resident received required assistance with activities of daily living (ADLs), specifically bathing, and inaccurate documentation that bathing had been provided. The resident, admitted in 10/2025 with dementia and stroke, had a 10/21/25 admission MDS indicating severe cognitive impairment and dependence on staff for showers. The facility’s 12/2025 CNA task report showed the resident was scheduled for bathing on day shift on Wednesdays and Sundays. On 12/24/25, the task report was blank for bathing, and on 12/28/25, the report documented that the resident received bathing and was dependent on staff for assistance. However, a 12/29/25 facility investigation determined the resident did not receive a bath on 12/28/25 and that it had been falsely documented that bathing occurred. A Facility Reported Incident form dated 12/31/25 further documented that on 12/28/25, a CNA (Staff 5) noted providing bathing to the resident but did not provide any type of bathing. Additional record review showed that the resident’s 3/2026 CNA task report contained no documentation that any type of bathing was provided on 3/11/26. Attempts to contact Staff 5 on 3/16/26 and 3/17/26 were unsuccessful. During interviews, another CNA (Staff 7) stated that on 12/28/25 she observed Staff 5 lay the resident down and, when she asked about bathing, Staff 5 said she would complete the resident’s bathing in the evening; Staff 7 stated she could not perform the resident’s bathing in the evening because she moved to a different hall on evening shift. Another CNA (Staff 21) stated that usually if bathing was not documented in the resident’s record, bathing did not occur. The Regional Nurse (Staff 31) stated that staff should provide scheduled bathing to residents.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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