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
A resident admitted with COPD had physician orders for BID doses of Combivent, Symbicort, and apixaban. Review of the MAR showed the evening doses of all three medications were not administered as ordered, and the Interim DNS confirmed they were missed. This failure to follow the medication orders placed residents at risk for not receiving medications as prescribed and potential side effects.
A resident with acute kidney failure and dependence on renal dialysis had a care plan specifying thrice-weekly dialysis with arranged transportation, but the facility failed to schedule transportation over a holiday period, leading to missed treatments and lack of documentation for one scheduled session. The receptionist reported being unable to set up transportation, and an LPN confirmed that staff knew transportation needed to be scheduled but the resident still missed a treatment. A family member was contacted by the dialysis center about the resident’s absence, found the resident very sick, and requested transfer to the ER, where dialysis was subsequently completed. The DNS acknowledged that the missed dialysis occurred because transportation had not been scheduled.
A hospice resident with COPD exacerbation and respiratory failure had PRN orders for oral morphine for SOB and moderate to severe pain but, according to multiple staff interviews and record review, an LPN refused to administer the ordered morphine during a period when the resident was screaming, anxious, disoriented, and exhibiting terminal agitation and SOB. Staff reported that the LPN declined to medicate the resident due to concern about depressing respirations, would not call hospice or the physician, and refused to provide the med cart keys to another LPN who attempted to follow the physician’s orders. CNAs and another LPN described the resident as having a very bad night with ongoing pain and distress, while the hospice care manager noted frustration with ordered medications not being administered and confirmed morphine was appropriate for the resident’s symptoms.
A resident with dementia and a history of falls was repeatedly kept up in a wheelchair at the nurse’s station for most of the night by an LPN, despite the resident’s stated desire to go to bed and the absence of any care-plan directive to keep the resident up all night. CNAs reported that when they attempted to put the resident to bed after incontinence care, the LPN ordered them to get the resident back up, refilled the resident’s coffee, and positioned the resident with a blanket, coffee, and magazines at the nurse’s station, stating she did not want to complete more incident reports for falls. Other nursing staff told the LPN this was abusive, and leadership later confirmed that keeping a resident at the nurse’s station all night for staff convenience was not acceptable, constituting involuntary seclusion.
Two residents experienced alleged abuse or neglect that was not reported to the State Survey Agency as required. One resident with COPD and respiratory failure had an order for PRN morphine for shortness of breath and pain, but an LPN allegedly refused to administer the medication despite reports of screaming, dyspnea, and anxiety, and no FRI was filed despite the Administrator and a unit manager being aware. Another resident with a hip fracture and dementia was allegedly kept in a wheelchair at the nurse’s station for most of the night and repeatedly given coffee so an LPN would not have to address falls or incident reports, and the Administrator allegedly instructed staff not to submit an FRI, with no investigation or report completed.
The facility failed to investigate two separate allegations of potential abuse and neglect. In one case, a resident with COPD and respiratory failure was reportedly denied ordered pain medication by an LPN despite reports of screaming, shortness of breath, and anxiety, and no investigation or documentation was completed to determine what occurred or rule out abuse/neglect. In the second case, a resident with a hip fracture and dementia was reportedly kept in a wheelchair at the nurse’s station for most of the night and repeatedly given coffee so an LPN would not have to address falls or incident reports, and again no investigation or documentation was completed despite leadership being notified.
A dependent resident with diabetes and urinary incontinence, care planned as requiring two-person assistance for all bed mobility and toileting, was being changed in bed by two CNAs when one left the room to obtain barrier cream, leaving the resident on their side with only one CNA present. While the remaining CNA was at the sink wetting a washcloth, the resident stated they were falling and was subsequently found on the floor by the returning CNA and an LPN. The resident was transferred to the hospital and later found to have bilateral femur fractures requiring surgery. Multiple staff, including CNAs, an RN, an LPN care manager, and the DNS, confirmed that the resident was fully dependent, could not roll independently, and should have had two staff present throughout care or been repositioned onto their back before any staff left.
A resident with multiple sclerosis, opioid use, and chronic pain, who was cognitively intact, experienced very low blood pressure and altered responsiveness during a night shift. A CNA noted the resident’s unusually deep sleep and lack of response during incontinence care and alerted an LPN, who confirmed low BP and later called the provider and 911. EMS records showed the resident was found altered earlier than the call time, and Narcan administration improved vital signs before hospital transfer, where the resident was treated for septic shock due to UTI and related complications. Facility policy required comprehensive baseline assessment and documentation of vital signs, neuro status, pain, level of consciousness, and onset/severity of condition, but the progress notes contained only limited information, and the Administrator acknowledged a delay in response and incomplete documentation.
A resident with multiple sclerosis, diabetes, and opioid use had a PRN order for naloxone (Narcan) nasal spray to be given in both nostrils for decreased responsiveness. During a surveyor observation of the emergency kit, only IV Narcan was found instead of the ordered nasal formulation. The facility Administrator confirmed that the correct nasal route Narcan was not available for this resident.
A dependent hospice resident with cancer, mixed bladder incontinence, and a coccyx pressure injury was not provided incontinent care or repositioning for about seven hours, despite a care plan requiring checks, changes, and turning at least every two hours. A CNA assigned to the resident acknowledged she only visually checked the brief once, did not change it, and did not reposition the resident due to the resident’s pain, and later wrote a note asking others to keep an LPN from entering the room because care had not been done. Other CNAs and the charge RN reported it was apparent the resident had not been changed, and staff confirmed that standard practice was to provide incontinence care and repositioning per the care plan.
Failure to Administer Ordered Respiratory and Anticoagulant Medications
Penalty
Summary
Facility staff failed to administer medications according to physician orders for one resident. The resident was admitted with diagnoses including chronic obstructive pulmonary disease and had admission orders dated 12/26/25 for Combivent 1 puff BID, Symbicort 2 puffs BID, and apixaban 5 mg BID. Review of the December 2025 MAR showed that the evening doses of Combivent, Symbicort, and apixaban were not administered on 12/26/25 as ordered. In an interview on 2/27/26 at 9:39 AM, the Interim DNS confirmed that these medications were not given as ordered on that date. This failure to administer the ordered evening doses of respiratory inhalers and an anticoagulant placed residents at risk for not receiving medications as ordered and potential side effects, as identified through interview and record review.
Failure to Arrange Transportation Resulting in Missed Dialysis Treatments
Penalty
Summary
The facility failed to provide transportation for a resident requiring scheduled dialysis treatments, resulting in missed dialysis sessions. The resident was admitted with diagnoses including acute kidney failure, dependence on renal dialysis, and metabolic encephalopathy. The resident’s care plan dated 11/22/25 documented that dialysis was to occur three days a week on Tuesday, Thursday, and Saturday, with transportation to the dialysis center to be provided and the resident to remain free from complications secondary to requiring dialysis. Progress notes showed the resident received dialysis at the hospital on 12/24/25 and did not receive treatment on 12/25/25, and there was no documentation of dialysis treatment on 12/27/25. In interviews, the receptionist stated that she or nursing staff assist with dialysis transportation planning and reported she was unable to set up the resident’s dialysis transportation over the December holiday. A family member reported receiving a call from the dialysis center asking why the resident was not present for dialysis and stated the resident was very sick and had not been admitted in that condition. The family member went to the facility and requested that staff send the resident to the ER for dialysis, which was completed on 12/29/25. An LPN stated that evening shift staff had informed her that the resident’s transportation to dialysis needed to be scheduled and confirmed the resident missed the dialysis treatment that was supposed to occur on 12/27/25. The DNS acknowledged that the resident missed dialysis due to transportation not being scheduled.
Failure to Administer Ordered Morphine for Hospice Resident in Distress
Penalty
Summary
The deficiency involves the facility’s failure to protect a hospice resident with COPD exacerbation and respiratory failure from neglect when ordered morphine for pain and shortness of breath was not administered. The resident had a physician’s order for morphine sulfate 0.25 ml by mouth every hour as needed for shortness of breath and/or moderate to severe pain. Progress notes documented that the resident experienced COPD exacerbation, groaning, difficulty breathing, thirst, distress, rapid breathing, anxiety, and difficulty swallowing. The medication administration record showed the resident received one dose of morphine on 11/6/25 at 8:38 PM, with no further doses given that day despite ongoing symptoms. Multiple staff interviews indicated that the LPN assigned to the resident’s care refused to administer the ordered morphine despite reports from other staff that the resident was screaming, anxious, short of breath, disoriented, and exhibiting terminal agitation behaviors such as pulling off clothes, screaming, and crying. Staff reported that the LPN stated she did not want to depress the resident’s breathing and would not listen to other staff, would not call hospice or the physician, and refused to give the medication cart keys to another LPN who attempted to medicate the resident per orders. CNAs and another LPN described the resident as having a very bad night, being in pain and distress the whole shift, and stated they believed the resident was being neglected. The hospice care manager reported hospice staff were frustrated with medication administration not being done as ordered and confirmed that morphine was appropriate for shortness of breath and could benefit the resident by slowing rapid breathing. The LPN later stated she did not remember if she gave the medication and did not provide further documentation or explanation.
Resident Kept at Nurse’s Station Overnight Against Wishes to Avoid Fall Reports
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from involuntary seclusion by keeping the resident up in a wheelchair at the nurse’s station for most of the night against the resident’s expressed wishes. The resident was admitted in 2025 with diagnoses including a hip fracture and dementia, and the care plan dated 12/2025 did not include any intervention to keep the resident at the nurse’s station all night to prevent falls. Despite this, on at least one night, the resident was kept at the nurse’s station until approximately 2:00–2:30 AM, provided incontinence care, and then returned to the nurse’s station and kept there until 5:00 AM, even though the resident requested to go to bed and did not usually stay up at night. Multiple staff interviews described that an LPN insisted on keeping the resident up at the nurse’s station because the resident had a history of falls and the LPN did not want to complete additional incident reports. CNAs reported that when they attempted to put the resident to bed after incontinence care, the LPN intervened and directed them to get the resident back up, despite the resident stating a desire to remain in bed. Staff observed the resident’s coffee cup being repeatedly refilled at night, which they stated was not normal for this resident, and the resident was positioned at the nurse’s station with a table, coffee, and magazines while being kept awake. Other nursing staff reported that on more than one night the LPN attempted to keep the resident up at the nurse’s station, tucking a blanket around the resident in the wheelchair and leaning the chair back while the resident stated being tired and wanting to go to bed. Staff stated they informed the LPN that forcing the resident to remain in the chair at the nurse’s station instead of allowing the resident to go to bed was abusive. The LPN acknowledged keeping the resident up at the nurse’s station due to concerns about falls and incident reports, and facility leadership confirmed that residents could be monitored at the nurse’s station but not for the entire night and not for staff convenience. This conduct resulted in the resident being subjected to involuntary seclusion and not being allowed to go to bed when requested.
Failure to Report Allegations of Abuse and Neglect to State Agency
Penalty
Summary
The facility failed to timely report allegations of abuse or neglect to the State Survey Agency for two residents. For one resident with COPD, acute exacerbation, and respiratory failure, a physician order dated 11/4/25 directed administration of morphine sulfate 0.25 ml by mouth every hour as needed for shortness of breath and/or moderate to severe pain. A former staff member reported that on 11/6/25, an LPN assigned to this resident refused to administer the ordered pain medication despite other staff reporting the resident was screaming, short of breath, and very anxious. The former staff member stated the Administrator was aware of the incident and spoke with the LPN, but no Facility Reported Incident (FRI) was submitted. The Administrator later acknowledged there was no FRI submitted, and the LPN/Unit Manager also confirmed awareness of the incident and that no FRI was reported. For another resident admitted with a hip fracture and dementia, a former staff member reported being notified that an LPN forced the resident to remain in a wheelchair at the nurse’s station for most of the night and continuously gave the resident coffee because the LPN did not want to deal with the resident falling and any potential incident reports. The former staff member stated she informed the Administrator of this incident and was told not to submit an FRI because it was handled in-house. The DNS stated there should have been an investigation of this incident and clarified that while residents may be monitored at the nurse’s station, it should not be for the entire night or for staff convenience. The Administrator acknowledged there was no FRI submitted to the State Survey Agency for this incident.
Failure to Investigate Allegations of Abuse and Neglect Involving Two Residents
Penalty
Summary
The facility failed to thoroughly investigate allegations of potential abuse and neglect involving two residents. For one resident with COPD with acute exacerbation and respiratory failure, a former staff member reported that on a specific date an LPN assigned to the resident refused to administer ordered pain medication despite reports from other staff that the resident was screaming, short of breath, and very anxious. The former staff member stated she was not informed of the incident at the time and therefore did not investigate it. The Administrator later acknowledged that no investigation was completed, could not provide any documentation showing an investigation or how abuse/neglect was ruled out, and stated she felt the incident was handled by the facility. The LPN involved stated she did not remember if she gave the medication and would need to check the medical record, but did not provide further information or documentation. Another LPN/Unit Manager confirmed awareness of the allegation that the LPN refused to give the resident morphine despite being told the resident was distressed, and also acknowledged that no investigation was completed. For a second resident with a hip fracture and dementia, a former staff member reported being notified that an LPN forced the resident to stay up in a wheelchair for most of the night at the nurse’s station and continuously gave the resident coffee because the LPN did not want to deal with the resident falling and any potential incident reports. The former staff member reported that she notified the Administrator of this incident. The DNS stated there should have been an investigation for this allegation and clarified that while residents could be monitored at the nurse’s station, this should not occur for the entire night or for staff convenience. The Administrator again acknowledged that no investigation was completed for this incident, could not provide any documentation of an investigation, and stated she felt the incident was handled by the facility.
Failure to Follow Two-Person Assistance Care Plan Resulting in Fall and Fractures
Penalty
Summary
The deficiency involves the facility’s failure to follow the care plan interventions requiring two-person assistance for bed mobility and incontinence care for a dependent resident, resulting in a fall with bilateral femur fractures. The resident, admitted in 2015 with diabetes and urinary incontinence, had an MDS assessment dated 1/9/26 and a care plan indicating dependence on staff for ADLs, including bed mobility and toileting, and specifically required two-person assistance. On 2/7/26, during incontinence care, two CNAs were assisting the resident, who was positioned on their side. One CNA (Staff 5) left the room to request barrier cream from an LPN (Staff 3), leaving the other CNA (Staff 4) alone with the resident. While Staff 5 was outside the room, Staff 4 obtained and wet a washcloth at the sink with the resident still on their side. The resident then yelled that they were rolling, and Staff 4 called for help. Staff 5 and Staff 3 entered the room and found the resident on the floor. Progress notes documented that the resident was transferred to the hospital after the witnessed fall and that the hospital later reported the resident required surgery on both legs due to bilateral femur fractures. The fall report, initiated on 2/7/26 and updated on 2/9/26, confirmed the sequence of events and the resulting injuries. In interviews, multiple staff members, including CNAs, an RN, an LPN/Care Manager, and the DNS, consistently stated that the resident was fully dependent, unable to perform bed mobility, and required two-person assistance for all bed mobility and incontinence care. They further stated that for a two-person dependent resident, both staff must remain with the resident for the duration of care, and the resident should not be left on their side unattended but should be repositioned onto their back before any staff leave the room. Staff 4 acknowledged in her statement that she was the only person in the room when the resident fell and that the resident should have been rolled onto their back before she left.
Failure to Timely Respond and Document Resident Change of Condition
Penalty
Summary
The deficiency involves staff failure to respond timely and completely to a resident’s change of condition and to document required baseline assessment data. The facility’s Acute Condition Changes-Clinical Protocol, revised 3/2018, required nurses to assess and document/report baseline information including vital signs, neurological status, current pain level, level of consciousness, and onset, duration, and severity of the condition. Resident 4, who had multiple sclerosis, opioid use, and chronic pain, was cognitively intact per a Quarterly MDS with a BIMS score of 15. On 11/25/25, a Blood Pressure Summary Report showed the resident’s blood pressure was 86/53 at 5:00 AM as taken by an LPN (Staff 6). A progress note at 6:50 AM documented the blood pressure as 70/50, and that Staff 6 called the provider and 911, but no additional assessment information was recorded. Interviews and external records showed that staff recognized abnormal findings and altered responsiveness but did not promptly act or fully document the change of condition. A CNA (Staff 14) reported that during the night the resident appeared to be sleeping, and at 5:00 AM the resident’s blood pressure was very low, prompting her to alert Staff 6. Staff 14 and Staff 6 provided incontinence care and noted it was unusual that the resident did not wake up during care and did not respond, despite typically waking when laid flat. Staff 6 stated the resident was unable to be awakened and had an abnormally low blood pressure, after which she called the provider and then 911. A Fire and Rescue Public Incident Report documented that the facility reported the resident was found with altered mental status at 5:00 AM, with EMS called at 6:46 AM and arrival at 6:50 AM, when Narcan was administered and vital signs improved. A subsequent hospital discharge summary documented admission for septic shock due to UTI, acute kidney injury, acute metabolic encephalopathy, and acute hypoxic/hypercapnic respiratory failure. The Administrator (Staff 1) acknowledged there was a delay in staff response to the change of condition and that the progress notes lacked the required baseline information.
Failure to Stock Correct Route of Ordered Emergency Narcan
Penalty
Summary
Surveyors found that the facility failed to provide the correct route of administration for an ordered emergency opioid antidote medication. A resident who was re-admitted in 12/2025 with multiple sclerosis, diabetes, and opioid use had a physician’s order dated 11/2025 for naloxone HCL (Narcan) nasal liquid 4 mg/0.1 mL to be administered in both nostrils as needed for decreased responsiveness. During an observation of the facility’s emergency kit on 2/19/26 at 12:34 PM, surveyors identified that Narcan was stocked only in an intravenous (IV) form rather than the prescribed nasal route for this resident. On 2/20/26 at 2:46 PM, the Administrator acknowledged that the facility did not have the correct nasal route formulation of Narcan available for the resident. This deficiency reflects the facility’s failure to obtain and maintain the ordered nasal formulation of naloxone in its emergency supply for a resident with an active PRN order for nasal Narcan for decreased responsiveness, as confirmed by observation of the emergency kit contents and staff acknowledgment.
Failure to Provide Timely Incontinence Care and Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinent care and repositioning assistance to a dependent resident over a seven-hour period. The resident had diagnoses including cancer and was on hospice, with a care plan indicating mixed bladder incontinence and dependence on staff for toileting. The care plan directed staff to check and change the resident during repositioning, as needed, and throughout the shift, and also documented a pressure injury to the coccyx with instructions for turn/repositioning at least every two hours and more often as needed. On the day in question, a CNA assigned to the resident did not provide incontinent care or repositioning for approximately seven hours of her shift, despite being responsible for these cares. Interviews and the facility’s investigation showed that the CNA acknowledged she had only looked at the resident’s brief early in the shift, thought it appeared dry, and left it unchanged, and that she did not reposition the resident because the resident grimaced in pain when she pulled on the pad. Other CNAs reported that the CNA wrote a note on the CNA message board asking others not to let the nurse enter the resident’s room because the resident had not yet been changed, and that it was obvious to staff later in the shift that the resident had not been changed. The charge nurse became aware near the end of the shift that the resident had not received care, and other CNAs were asked to assist with completing the resident’s cares. Staff interviews confirmed that standard practice was to provide incontinence care and repositioning at least every two hours or according to the care plan, and the administrator acknowledged that the resident was not provided ADL assistance by the CNA for a prolonged period of time.
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