Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Valley West Health Care Center during CMS and state inspections, most recent first.
A resident with a history of amputation, mood disturbance, and anxiety was physically abused by a CNA during personal care when the CNA struck the resident's wrist multiple times after the resident became verbally agitated and flailed their arms. The CNA self-reported the incident, and a bruise was later observed on the resident's wrist. Facility investigation confirmed the abuse.
The facility did not have an RN on duty for at least 8 consecutive hours on several days, as confirmed by staffing records and the administrator. This resulted in periods where residents' assessment needs may not have been met.
Staff were observed discarding used PPE in garbage bins located outside resident rooms, rather than inside as required by CDC Enhanced Barrier Precautions. Facility management had directed staff to follow this practice, and the RN Infection Preventionist confirmed the facility was not adhering to CDC guidelines, resulting in a failure to implement proper infection control measures.
Four residents were either not offered the pneumococcal vaccine or, after consenting, did not receive it. Two residents with chronic conditions were eligible but not offered the vaccine, while two others consented but had no documentation of receiving it, as confirmed by staff and record review.
A resident with heart failure was admitted to hospice, but the required Significant Change MDS assessment was not completed within the mandated 14-day period. The assessment was performed 27 days after hospice admission, as confirmed by the RN MDS Coordinator.
A resident with schizophrenia, polydipsia, and a history of suicidal ideation exhibited ongoing psychiatric symptoms and behaviors, including excessive fluid intake and auditory hallucinations. Despite multiple hospitalizations and documentation of serious mental illness, staff did not complete a required PASARR Level II referral, and interviews confirmed the oversight.
Two residents did not receive care according to physician orders: one did not have prescribed blood glucose checks performed after admission despite orders and prior home practice, and another received antiviral medication for a herpes outbreak less frequently than ordered, with staff administering it only upon request rather than as scheduled.
A resident with hypothyroidism had a physician order for a TSH lab that was not completed until more than a month after it was ordered. An LPN acknowledged the delay in processing the lab order, resulting in unmet needs for the resident.
A resident with muscle weakness and depression, who was care planned for one-person assistance during bathing, was left alone in the shower room by a CNA unfamiliar with the resident's needs. The resident reported feeling unsafe, and staff interviews confirmed the care plan was not followed, resulting in a deficiency related to inadequate supervision and accident prevention.
Physical Abuse of Resident by CNA During Personal Care
Penalty
Summary
A resident with a history of below the knee amputation, mood disturbance, and anxiety was involved in an incident where a CNA engaged in physical abuse during personal care. The resident became verbally agitated and flailed their arms at the CNA, who responded by grabbing the resident's wrists in an attempt to calm them. The CNA then struck the resident's left wrist area three times with her fist. The CNA immediately left the room, self-reported the incident to a nurse, and was visibly upset. An initial skin assessment showed no injury, but a small bruise and pain with movement were noted shortly after. The facility's investigation confirmed that the CNA had physically abused the resident by hitting their wrist after attempting to restrain them. The CNA admitted to the action, stating she felt threatened but acknowledged the resident had not actually attempted to hit her. The administrator and other staff confirmed the occurrence of physical abuse. The resident recalled the incident and expressed not wanting care from the CNA again. The event was documented in incident and progress notes, and the abuse was substantiated through the facility's investigation.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to staff a registered nurse (RN) for at least 8 consecutive hours per day, 7 days per week, as required. Review of the Direct Care Staff Daily Report showed that there were no RNs scheduled on five specific dates within the 34-day review period. This was confirmed by the facility administrator, who acknowledged the absence of RN coverage on those dates. The lack of RN coverage placed residents at risk for unmet assessment needs during those times.
Failure to Follow CDC Enhanced Barrier Precautions for PPE Disposal
Penalty
Summary
The facility failed to follow CDC Infection Control Guidelines related to Enhanced Barrier Precautions for all 13 sampled resident rooms reviewed for infection control. Specifically, the CDC's guidelines require that a trash bin for discarding personal protective equipment (PPE) be placed inside the resident room and near the exit, so that used PPE can be removed and discarded prior to exiting the room. However, observations revealed that in each of the sampled rooms, the garbage bins for used PPE were placed outside the resident rooms in the hallway, rather than inside as required. Staff were observed donning PPE, entering resident rooms, and then doffing and discarding used PPE in bins located outside the rooms after exiting, contrary to CDC guidelines. Interviews with staff confirmed that they had been instructed by facility management to discard used PPE in garbage bins outside the resident rooms. The RN Infection Preventionist acknowledged that the facility was not following CDC guidelines regarding the placement of garbage bins for PPE disposal. These actions and facility practices resulted in a failure to implement proper infection prevention and control measures as outlined by the CDC, placing residents at risk for exposure to infections and cross-contamination.
Failure to Offer and Administer Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure that residents were offered and received pneumococcal vaccines as required by their policy. Specifically, four out of seven sampled residents were either not offered the vaccine or, after consenting, did not receive it. The facility's policy states that each resident should be offered the pneumococcal immunization unless medically contraindicated or previously immunized, and that consents or declinations should be documented in the medical record. However, two residents admitted with diagnoses of heart failure and diabetes were eligible but were not offered the vaccine, as confirmed by the RN Infection Preventionist. Additionally, two other residents, one with kidney failure and another with heart failure, were offered and consented to receive the pneumococcal vaccine, but there was no documentation that the vaccine was administered. The lack of documentation and follow-through on vaccine administration for these residents was confirmed during staff interviews and record reviews, with no further information provided by facility staff.
Delayed Significant Change MDS Assessment for Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment within the required 14-day timeframe for a resident who was admitted to hospice services. The resident, who had a diagnosis of heart failure and was admitted to the facility in December 2024, began receiving hospice care on April 25, 2025. However, the Significant Change MDS assessment was not completed until May 21, 2025, which was 27 days after the resident's admission to hospice. This delay was confirmed by the RN MDS Coordinator, who acknowledged that the assessment was not performed within the mandated period.
Failure to Complete PASARR Level II Referral for Resident with Serious Mental Illness
Penalty
Summary
The facility failed to complete a referral for a Level II PASARR (Pre-Admission Screening and Resident Review) for a resident with a documented history of serious mental illness. The resident was admitted with diagnoses including schizophrenia, polydipsia, hyponatremia, and panic disorder. Initial PASARR Level I completed by the hospital did not indicate serious mental illness, but subsequent documentation, including a later Level I, hospital discharge summaries, and provider notes, revealed ongoing symptoms such as suicidal ideation, auditory hallucinations, and behaviors related to excessive fluid intake. Despite these indicators, there was no evidence in the medical record that a Level II PASARR referral was made. Staff interviews confirmed the resident exhibited behaviors consistent with serious mental illness, including verbal outbursts, paranoia, and noncompliance with fluid restrictions, which led to repeated hospitalizations for hyponatremia and suicidal ideation. Social services staff acknowledged the lack of current mental health involvement and the absence of a Level II PASARR referral. The unit manager and administrator both agreed that a referral should have been completed, but it was not done.
Failure to Follow Physician Orders for Blood Glucose Monitoring and Medication Administration
Penalty
Summary
The facility failed to follow physician orders for two residents regarding blood glucose monitoring and medication administration. One resident with a diagnosis of diabetes was admitted with orders for capillary blood glucose (CBG) checks three times daily, as indicated in both the hospital after-visit summary and a nurse practitioner note. Despite these orders and the resident's report of frequent CBG monitoring at home, the clinical record showed that staff did not perform or document any CBG monitoring after admission. Multiple staff interviews confirmed that the orders for CBG monitoring were entered into the electronic record but were not implemented by nursing staff. Another resident with a diagnosis including herpes virus infection had a physician order for acyclovir to be administered twice daily as needed for a herpes outbreak. Review of the medication administration record (MAR) revealed that the resident received acyclovir only once daily, except for one day when it was given twice. Staff confirmed that the medication was administered only when the resident requested it, rather than according to the prescribed twice-daily schedule.
Delayed Processing of Physician Lab Order for TSH
Penalty
Summary
The facility failed to process a physician's laboratory order in a timely manner for one resident with a diagnosis of hypothyroidism. A physician order for a TSH (Thyroid Stimulating Hormone) lab was placed on 2/19/25, but the lab was not completed until 3/25/25, resulting in a delay of over one month. This delay was confirmed by the LPN Unit Care Coordinator, who acknowledged that the TSH lab was not completed in a timely fashion. The deficiency was identified through interview and record review, and it was noted that this failure placed residents at risk of unmet needs.
Failure to Provide Required Bathing Assistance
Penalty
Summary
A deficiency occurred when a resident, admitted with depression and muscle weakness and assessed as cognitively intact, was not provided the required one-person assistance during bathing as specified in their care plan. On the date of the incident, a CNA escorted the resident to the shower room, set them up, and then left the resident alone to shower independently, contrary to the care plan instructions. The resident later reported feeling unsafe and described the experience as neglectful, although no physical harm was reported. Staff interviews confirmed that the CNA assigned to the resident was unfamiliar with the resident's specific needs and, despite reading the care plan, failed to provide the necessary assistance. Another CNA responded to the call light and found the resident alone in the shower room, subsequently staying with the resident and notifying the assigned CNA. The incident was verified by facility staff, and it was acknowledged that the required supervision was not provided during the bathing process.
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 158 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — 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 Eugene
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avamere Rehabilitation Of Eugene | 1.5 mi | ★★★★★ | 17 | 1 |
| Hillside Heights Rehabilitation Center | 2 mi | ★★★★★ | 14 | 0 |
| Cascade Manor | 3 mi | ★★★★★ | 4 | 0 |
| South Hills Rehabilitation Center | 3.5 mi | ★★★★★ | 22 | 1 |
| Creekside Health And Rehabilitation Of Cascadia | 3.6 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Valley West Health Care 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 July 2026) and official state health department websites.