Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Umpqua Valley Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Incomplete Narcotic Count Documentation: The facility failed to maintain accurate narcotic records and complete controlled substance counts for 4 of 4 med carts reviewed. Surveyors found numerous missing signatures in the narcotic logbooks across multiple carts, and CMAs reported that two staff members were required to reconcile and sign the narcotic count at the end of each shift. The DNS later verified the missing signatures and confirmed the expected process.
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.
Unnecessary PRN Psychotropic Medication Use Without Documented Rationale: A resident with depression and dialysis dependence had PRN trazodone ordered for sleep with no end date and was given it frequently over several months. Pharmacy review noted the medication was past the 14-day requirement and requested a clinical rationale or discontinuation, but the record contained no documented rationale for continued use, and an LPN acknowledged the ongoing use without documentation.
A resident with dementia and a history of falls was assessed as high fall risk due to wandering, poor memory, frequent self-transfers, and impulsive behavior. The resident later had an unwitnessed fall while trying to reach the bathroom, and when placed on droplet isolation for Covid-19, staff kept the bedroom door closed, making monitoring difficult while staff reported the resident continued to attempt unassisted bed exits and self-transfers.
Failure to provide ordered PT occurred for a resident admitted with stroke-related weakness and reduced mobility. A provider ordered a PT evaluation, but the resident was not seen by therapy. The resident said wanting PT to walk again and felt frustrated because PT had been promised and never received. An LPN, the RCM, and the DNS each stated they were unaware of the PT order or expected the provider or floor staff to communicate and review the order.
Improper Catheter Bag Placement: A resident admitted with a UTI had a catheter bag and tubing observed lying on the floor, with a CNA stating it was placed there because the bed was in the lowest position. An LPN Resident Care Manager later confirmed the setup and stated it was not appropriate infection control related to catheter care.
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.
Incomplete Narcotic Count Documentation
Penalty
Summary
The facility failed to ensure narcotic records were maintained accurately and that an account of all controlled substances was kept for 4 of 4 medication carts reviewed. On 8/20/25, surveyors reviewed the narcotic logbooks for the Skilled Hall medication cart, the 200/300 hall medication cart logbook number 13, the 200/300 hall medication cart logbook number 15, the 100/300 hall medication cart logbook number 20, and the TCU hall medication cart. Each logbook showed numerous instances in which facility staff did not sign to verify the narcotic count, including 114 of 300 opportunities on the Skilled Hall cart, 126 of 300 on logbook number 13, 129 of 300 on logbook number 15, 92 of 300 on the 100/300 hall cart, and 110 of 300 on the TCU hall cart. Staff interviews confirmed the expected process for narcotic reconciliation. Staff 15 (CMA) stated that two staff members, either a CMA or licensed nurse, are required to reconcile narcotics at the end of each shift and both must sign the narcotic logbook to show the count is correct, with Staff 2 (DNS) to be notified if the reconciliation is not accurate. Staff 16 (CMA) gave the same explanation. Staff 2 later verified the missing signatures in the narcotic logbooks and stated the process required two nurses or CMAs to verify the narcotic count was accurate.
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.
Unnecessary PRN Psychotropic Medication Use Without Documented Rationale
Penalty
Summary
The facility failed to ensure a resident was free from unnecessary medications and failed to provide a clinical rationale for continued PRN psychoactive medication use beyond 14 days. Resident 75, who was readmitted in 2024 with diagnoses including depression and dialysis dependence, had a 6/5/25 physician order for trazodone in the evening as needed for sleep with no end date listed. Review of the MARs showed the PRN trazodone was administered frequently across multiple months, including 19 doses out of 26 days in 6/2025, 22 doses out of 31 days in 7/2025, and 12 doses out of 18 days in 8/2025. A 7/25/25 pharmacy review noted the PRN trazodone had been requested 19 times in the past 30 days and stated it was past the 14-day requirement, recommending discontinuation or a clinical rationale and duration. The medical record contained no clinical rationale for continuing the PRN trazodone beyond the required 14 days, and on 8/21/25 Staff 5 acknowledged the resident continued to use the medication and that no rationale was documented.
Inadequate Supervision for High Fall-Risk Resident on Isolation
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for one resident who was reviewed for falls. The resident was admitted with diagnoses of dementia and a history of falls. A care assessment noted increased fall risk related to a personal history of falls, wandering behavior, poor memory, frequent self-transfers, and dementia, and staff were directed to anticipate the resident’s needs and perform frequent safety checks. A nursing facility incident form documented that the resident had an unwitnessed fall while attempting to reach the bathroom in the room. Later, when the resident tested positive for Covid-19 and was placed on droplet isolation, staff were required to keep the bedroom door closed. Observation over several days showed the resident remained in the room with staff entering only when the call light was activated. Staff stated the resident was impulsive, attempted to exit the bed unassisted, displayed forgetfulness and attempted self-transfers, and that the closed door made monitoring difficult. The DNS stated that high fall-risk residents were expected to be checked every 30 minutes even when on precautions.
Failure to Provide Ordered Physical Therapy
Penalty
Summary
Failure to provide specialized rehabilitative services occurred for one resident who was admitted with diagnoses including stroke with weakness to the non-dominant side. A provider encounter note dated 7/10/25 documented an order for physical therapy evaluation due to reduced mobility, but the resident was not evaluated by therapy. On 8/19/25, the resident stated wanting physical therapy in order to walk again and said feeling frustrated because PT had been promised and never received. On 8/20/25, an LPN stated that after reviewing provider notes following a physician visit, he checked for new orders and entered them into the system, and said he would print any therapy order if present, but he was unaware the resident had PT orders. On 8/21/25, the RCM stated she was unaware of the PT orders from 7/2025 and expected the provider to tell floor staff or enter the therapy orders into the EMR. The DNS acknowledged the resident had PT orders from 7/2025 and was not evaluated by therapy, and stated she expected the provider to inform floor staff of therapy orders and for floor staff to review provider notes.
Improper Catheter Bag Placement
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when the facility failed to follow proper infection control precautions for 1 of 1 sampled resident reviewed for infection control. Resident 60 was admitted in 8/2025 with diagnoses including a urinary tract infection. On 8/20/25 at 12:38 PM, the resident’s catheter bag and tubing were observed lying on the floor. At 1:00 PM, a CNA stated the catheter bag had been placed on the floor with a towel underneath because the resident’s bed was in the lowest position. At 1:08 PM, the LPN Resident Care Manager entered the room, confirmed the catheter bag and tubing were on the floor with a towel underneath, and stated this was not appropriate infection control related to catheter care.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 11 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Roseburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rose Haven Nursing Center | 1 mi | ★★★★★ | 11 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Umpqua Valley Nursing & Rehabilitation Center.
100% money-back within 48 hours.
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.