Citations in Oregon
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Oregon.
Statistics for Oregon (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Oregon
Staff failed to properly disinfect reusable medical equipment, including vital sign equipment and a community-use glucometer, between resident uses, and used personal care wipes instead of EPA-approved disinfectant wipes. An LPN did not clean a glucometer between residents until prompted by a surveyor. During meal service, a nursing assistant delivered food trays to multiple rooms and a family member without performing hand hygiene between rooms. These lapses were confirmed by supervisory staff and placed residents at risk for cross-contamination.
A resident with insomnia and depression was prescribed quetiapine fumarate, with the dosage increased over time. There was no documentation that the resident was informed of the risks and benefits of this antipsychotic medication, as confirmed by the DNS.
A resident with multiple sclerosis and lower extremity ROM impairment did not receive prescribed passive ROM exercises as outlined in their care plan. Documentation and staff interviews confirmed that restorative services were not consistently provided, and CNAs were unaware or did not perform the required exercises after the facility transitioned responsibility from a designated restorative aide.
Two residents with chronic conditions did not have their advance directives available in their clinical records, despite care plans indicating these documents should be present and honored. Staff were unable to locate the advance directives and confused POLST forms with advance directives, confirming the documents were missing from the records.
An LPN was observed preparing insulin glargine for a resident using a vial that did not have an open date labeled, despite manufacturer instructions requiring the medication to be discarded 28 days after opening. The LPN confirmed the vial was open without the necessary labeling, resulting in a failure to follow proper medication labeling protocols.
A resident with blindness did not receive a new lower denture as ordered by a physician, despite attending a dental appointment. The resident reported not receiving the denture and was unsure why. Both social services and the LPN resident care manager were unaware of the order and confirmed that no follow-up had occurred after the appointment.
A resident with limited mobility and a neck fracture, who required two-person assistance for transfers, was injured when a CNA attempted to transfer the resident alone from the commode. This failure to follow the resident's care plan resulted in a fall and a fractured right arm, as confirmed by facility staff and medical records.
A deficiency was cited when an area of the facility was not kept free from accident hazards and adequate supervision was not provided to prevent accidents. The environment and supervision protocols were found to be insufficient to minimize accident risks.
A resident with multiple sclerosis and overactive bladder, who required two-person assistance for toileting, was assisted by only one CNA, resulting in a fall from bed. The CNA disregarded the care plan and provided care alone, and facility leadership confirmed the care plan was not followed.
A resident with dementia and a femur fracture, whose POA requested a specific CNA be removed from their care following a grievance, continued to receive ADL care and vital sign assessments from that CNA despite a documented resolution. Facility records and staff interviews confirmed the CNA's ongoing involvement in the resident's care after the grievance was addressed.
Failure to Disinfect Reusable Equipment and Perform Hand Hygiene
Penalty
Summary
Facility staff failed to follow appropriate disinfection practices for reusable medical equipment, including vital sign equipment and community-use glucometers. On multiple occasions, a CNA was observed moving a rolling vitals cart with reusable equipment from one resident room to another without cleaning the equipment between uses. When questioned, the CNA used personal care wipes instead of the required EPA-approved disinfectant wipes, stating that CNAs no longer had access to the proper wipes. The Director of Nursing Services confirmed that only EPA-approved Super Sani-Cloth wipes were acceptable for disinfecting reusable equipment, and personal care wipes did not contain the necessary germicide. Additionally, an LPN was observed using a community-use glucometer on one resident and then preparing to use it on another without cleaning it in between, only disinfecting it after intervention by a surveyor. The LPN acknowledged forgetting to clean the glucometer, and the DNS reiterated the expectation to use EPA-approved wipes and observe the required dwell time between uses. During meal service, a nursing assistant was observed delivering food trays to multiple resident rooms and to a family member without performing hand hygiene between rooms. The staff member admitted to not performing hand hygiene after leaving resident rooms during meal service. The LPN Resident Care Manager confirmed that staff were expected to perform hand hygiene after leaving each resident room during meal service. These failures were observed on one of four halls reviewed for infection control and meal service, and involved at least one sampled resident during medication pass.
Failure to Inform Resident of Psychotropic Medication Risks and Benefits
Penalty
Summary
The facility failed to inform a resident of the risks and benefits associated with the use of a psychotropic medication. The resident, who was admitted with diagnoses of insomnia and depression, was prescribed quetiapine fumarate initially at 25mg for insomnia, which was later increased to 50mg for depression. Review of the resident's medical record showed no documentation that the resident was informed about the risks and benefits of quetiapine fumarate. This was confirmed by the Director of Nursing Services, who acknowledged the absence of such evidence in the medical record.
Failure to Provide Prescribed Restorative ROM Services
Penalty
Summary
A resident with multiple sclerosis, admitted in August 2022, was identified as requiring passive range of motion (ROM) exercises for both lower extremities to address impairments and prevent further decline. The resident's care plan, last revised in August 2025, included a restorative nursing program specifying bilateral knee and right hip passive ROM exercises. However, review of the resident's ROM Program Task tracking form and the restorative nursing services binder from early August to early September 2025 revealed no documentation that these restorative services were provided. The most recent Minimum Data Set (MDS) assessment also indicated that the resident did not receive passive ROM during the look-back period, despite being cognitively intact and having documented ROM impairment. Interviews with the resident and multiple staff members confirmed that the resident was not receiving the prescribed ROM exercises. The resident reported that staff no longer provided ROM exercises for their legs. Certified Nursing Assistants (CNAs) interviewed were either unaware of the resident's need for restorative services or confirmed they had not provided the exercises. The LPN Resident Care Manager acknowledged the resident's restorative program and stated that, following the absence of a designated restorative aide, CNAs were responsible for delivering these services, which were expected to be provided according to the care plan.
Failure to Maintain Advance Directives in Resident Records
Penalty
Summary
The facility failed to ensure that advance directives were available in the clinical records for two of four sampled residents. For one resident with a history of diabetes, the care plan indicated the presence of an advance directive and a medical power of attorney, but neither document was found in the medical record. The resident confirmed having completed an advance directive with family, and the care plan required that the directive be honored and kept on file. However, staff were unable to locate the document and were unclear about the distinction between a POLST and an advance directive, using the terms interchangeably. Similarly, another resident with multiple sclerosis had a care plan stating an advance directive was in place and should be honored, but the document was not present in the clinical record. The resident reported completing an advance directive while at the facility. Staff again referenced a POLST as being on file and demonstrated a lack of understanding regarding the difference between a POLST and an advance directive. In both cases, the absence of the required documentation in the medical record was confirmed by staff.
Insulin Vial Lacked Required Open Date Label
Penalty
Summary
A deficiency was identified when, during observation, an LPN prepared insulin glargine for a resident using a vial that did not have an open date labeled. The manufacturer's instructions for insulin glargine require the medication to be discarded 28 days after opening, making the open date essential for proper medication management. The LPN acknowledged that the insulin vial was open but lacked the required open date, indicating a failure to ensure proper labeling of biologicals as required by professional standards.
Failure to Assist Resident in Obtaining Ordered Denture
Penalty
Summary
The facility failed to assist a resident with obtaining a new lower denture as ordered by the physician. The resident, who was blind and had no dental concerns noted at admission, had a physician's order and progress note indicating the need for a new bottom denture. However, there was no documentation in the clinical record regarding any follow-up or completion of this order. The resident reported having had a dental appointment two months prior and was expecting to receive the denture but had not received it and was unaware of the reason. Staff responsible for social services and resident care management were both unaware of the order and acknowledged that no follow-up had been completed since the dental appointment.
Failure to Follow Care Plan Results in Resident Fall and Fracture
Penalty
Summary
A resident with a history of neck fracture and limited mobility was admitted to the facility and required a two-person assist for transfers during toileting, as documented in the care plan. Despite this, a CNA attempted to transfer the resident alone from the commode, resulting in the resident slipping and falling to the floor. The fall led to a fracture of the resident's right arm. The resident was cognitively intact at the time, with a BIMS score of 15 out of 15, and was aware of the care plan requirements for two-person assistance during transfers. Interviews and record reviews confirmed that the CNA did not follow the resident's individualized care plan, which specifically required two-person assistance for transfers and toileting. Facility staff, including the RCM and Administrator, acknowledged that the failure to adhere to the care plan directly led to the resident's fall and subsequent injury. The incident was substantiated by the facility's investigation and the resident's hospital discharge summary, which documented the right arm fracture resulting from the fall.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Follow Two-Person Assistance Care Plan During Toileting
Penalty
Summary
Staff failed to follow the care plan for a resident with multiple sclerosis and overactive bladder, who was cognitively intact but dependent on others for toilet hygiene. The resident's care plan required two-person assistance for toileting. However, during an incident, an agency CNA provided toileting care alone without a second staff member, contrary to the care plan. As a result, the resident fell out of bed while being assisted. The resident reported that the CNA stated she could provide care without assistance, and facility leadership acknowledged that the care plan was not followed at the time of the fall.
Failure to Honor Grievance Resolution Regarding Resident Care Assignment
Penalty
Summary
The facility failed to honor a grievance resolution for a resident with dementia and a femur fracture, who had significant cognitive impairments. A grievance was filed by the resident's Power of Attorney (POA) after a CNA forced the POA to leave the resident's room during care and subsequently left the room when the POA requested to stay. The POA requested that this CNA no longer provide care to the resident, and the Director of Nursing Services documented that the resolution was for the CNA to be removed from providing care to this resident. Despite this documented resolution, facility records showed that the CNA continued to provide ADL care, including brief changes, oral hygiene, showers, and vital sign assessments to the resident on multiple occasions after the grievance was resolved. The POA observed the CNA providing care on at least one occasion and reported this to facility staff. The Director of Nursing Services confirmed that records indicated the CNA continued to provide care to the resident after the grievance resolution.
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