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 with cognitive impairment and a legal guardian was allowed to leave the facility twice without appropriate care plan revisions or interventions. Staff failed to recognize the resident's lack of decision-making capacity, did not use the guardian's emergency contact as directed, and did not investigate the elopement incidents, resulting in inadequate supervision and repeated elopements.
Facility administration did not ensure effective use of resources, resulting in chronic insufficient staffing, delayed resident assistance, and incomplete facility assessments. A resident with epilepsy did not receive seizure medication on time, leading to a seizure and hospitalization, with no incident report completed or follow-up with the responsible LPN.
A facility-wide assessment was found to be incomplete, lacking accurate information on how staffing needs and resident acuity were addressed, and failing to account for high agency staff usage. The Administrator confirmed the assessment was not comprehensive and did not contain accurate staffing data.
The facility did not maintain adequate nursing staff, leading to prolonged call light response times, delayed medication administration, missed meals, and incomplete care such as incontinence care and showers. Staff and family interviews, public complaints, and facility records all confirmed frequent staffing shortages, especially on nights and weekends, with state minimum staffing ratios for CNAs unmet on numerous days. One resident requiring substantial assistance reported long waits for care, and staff acknowledged that assignments were not made timely and inexperienced staff were orienting each other.
A resident with epilepsy and dementia did not receive scheduled anti-seizure medications on time when an LPN administered them several hours late and delayed documentation. The resident, who had no prior seizures in the facility, subsequently experienced multiple seizures and required hospitalization. The DNS was informed after a family member raised concerns, and no incident report or staff follow-up occurred.
A resident with epilepsy and dementia experienced a seizure and was sent to the hospital, but the emergency contact was not notified by facility staff. The family member only learned of the incident from hospital staff, and facility leadership confirmed the lack of notification.
A resident with a seizure disorder did not receive prescribed anti-seizure medication for several days due to pharmacy supply issues and lack of timely review of new medication orders by staff. Multiple staff members confirmed that medication orders were not properly reviewed or followed up, resulting in missed doses.
The facility did not consistently post accurate and complete nurse staffing information, with multiple days showing blank or incorrect entries for daily census, staff numbers, and hours worked. This issue was confirmed by the Administrator.
A resident with significant mobility and skin integrity risks developed multiple new pressure ulcers over several months. Despite existing care plan interventions, staff did not document reassessment or implement additional interventions after new wounds appeared. Nursing staff acknowledged that further measures should have been taken, but these were not documented or followed up.
A resident undergoing evaluation for TB was not consistently placed on airborne precautions as ordered. The resident participated in group therapy and communal activities without a mask, and staff frequently entered the shared room without PPE or following infection control protocols. The airborne precaution signage was incomplete, and staff were not fully aware of the required practices, resulting in a failure to implement proper infection control measures.
Failure to Revise Care Plan and Ensure Supervision After Resident Elopement
Penalty
Summary
The facility failed to revise care plan interventions and re-evaluate a resident's elopement risk, resulting in inadequate supervision and failure to prevent repeated elopements for a resident with significant cognitive and physical impairments. The resident, who had diagnoses including psychosis, delusional disorder, schizophrenia, and suspected vascular dementia, was under guardianship and had documented impaired strength, balance, and endurance. Despite these factors, the care plan did not address the resident's elopement incidents, and no new interventions were developed after the resident left the facility on two occasions. Progress notes indicated the resident expressed a desire to leave, and staff allowed the resident to leave against medical advice (AMA), only leaving a voice message for the guardian rather than using the emergency contact as specified in the guardianship paperwork. Staff interviews revealed a lack of awareness regarding the resident's guardianship status and the appropriate procedures for contacting the guardian. Staff members believed the resident was alert and oriented and had the right to leave, despite documentation indicating the resident lacked decision-making capacity. The facility did not conduct investigations into either elopement incident, and staff failed to notify law enforcement or use the correct emergency contact methods. The guardian confirmed that she was not contacted appropriately and reiterated that the resident did not have the capacity to make decisions about leaving the facility.
Failure to Ensure Effective Administration, Sufficient Staffing, and Timely Medication Administration
Penalty
Summary
Facility administration failed to use resources effectively and efficiently, resulting in insufficient staffing, lack of a comprehensive facility assessment, and significant medication errors. Observations over multiple days revealed delayed responses to call lights, staff appearing rushed, and residents waiting for assistance, leading to resident frustration. Facility documentation and interviews with residents and staff confirmed ongoing concerns about inadequate staffing, with reports of staffing levels below state minimums and not adjusted for resident acuity. Staff reported these issues to administration, but no changes were made, and the facility assessment did not accurately address staffing needs or the high use of agency staff. Additionally, a resident with epilepsy did not receive scheduled seizure medication on time, with a dose administered over two hours late. Subsequently, the resident experienced an active seizure and was sent to the hospital. The DNS became aware of the incident only after a family member raised concerns, and no incident report was completed, nor was the responsible LPN interviewed about the event. These failures contributed to the facility not attaining or maintaining the highest practicable well-being of residents.
Incomplete Facility Assessment for Staffing and Acuity
Penalty
Summary
The facility failed to conduct and complete a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. Review of the facility assessment dated 3/24/25 revealed it was not comprehensive and did not accurately include information on how the assessment was used to address staffing needs or resident acuity, nor did it reflect the high usage of agency staff. During an interview, the Administrator acknowledged that the assessment lacked accurate and comprehensive information related to staffing. No additional information was provided to address these deficiencies.
Failure to Provide Sufficient Nursing Staff Resulting in Delayed Care and Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple observations, interviews, and record reviews. On several occasions, residents experienced long call light response times, with documented waits of up to 33 minutes for assistance with basic needs such as toileting and receiving water. Family members and residents reported delays in medication administration, missed meals, and untimely incontinence care. Staff interviews confirmed ongoing shortages of CNAs, CMAs, and nurses, particularly on night and weekend shifts, resulting in incomplete care tasks such as showers, vital signs, and restorative care. Staff also reported that assignments were not made timely, residents were not divided evenly, and inexperienced staff were orienting each other. Public complaints submitted to the State Agency corroborated these findings, with allegations of untimely toileting assistance, long call light response times, and inaccurate reporting of CNA hours. Facility records showed that state minimum staffing ratios for CNAs were not met on 46 out of 115 days reviewed. Staff responsible for scheduling indicated that staffing decisions were based on minimum state requirements, and upper management determined when additional staff were needed based on acuity. However, there was acknowledgment from both staff and administration of ongoing staffing challenges and frequent call-ins, especially on weekends. One resident, admitted with a history of repeated falls and depression, required substantial assistance with transfers and toileting. This resident filed a grievance regarding insufficient night shift staffing and long call light response times, which was substantiated by facility records showing a CNA shortage on the reported date. The Director of Nursing Services stated she was not involved in staffing assessments, and the administrator confirmed that no facility assessment for staffing levels based on resident acuity was available.
Significant Medication Error Leads to Resident Seizures and Hospitalization
Penalty
Summary
A deficiency occurred when a resident with epilepsy and dementia did not receive prescribed anti-seizure medications (levetiracetam, lamotrigine, and zonisamide) at the scheduled time. The physician's order required these medications to be administered twice daily at 8:00 AM and 8:00 PM. On one occasion, an LPN administered the medications significantly late, at approximately 10:30 PM, and did not document the administration until 11:47 PM. Prior to this incident, the resident had no recorded seizures in the facility. Following the late administration, the resident experienced multiple seizures, including one lasting about ten minutes, and was subsequently sent to the hospital via ambulance. The DNS became aware of the incident after a family member raised concerns about the timing of medication administration. The DNS confirmed that timely administration of anti-seizure medications is important and noted that the facility was not conducting routine lab monitoring for levetiracetam levels. No incident report was completed, and the DNS did not discuss the event with the LPN involved.
Failure to Notify Responsible Party of Resident's Change in Condition
Penalty
Summary
The facility failed to notify a resident's responsible party of a significant change in condition for one resident who was admitted with diagnoses including epilepsy and dementia. According to the clinical record, the resident experienced an active seizure and was subsequently sent to the hospital by emergency services. Documentation showed that the on-call staff and the administrator were notified, but there was no evidence that the resident's emergency contact, a family member, was informed of the seizure or hospitalization. The family member later confirmed that she was unaware of the incident until contacted by hospital staff. Facility leadership acknowledged that the emergency contact was not notified regarding the resident's change in condition and hospitalization.
Failure to Administer Anti-Seizure Medication as Ordered
Penalty
Summary
A resident with a history of seizures and respiratory failure was admitted to the facility with a physician's order for felbamate, an anti-seizure medication, to be administered twice daily. Despite this order, the medication was not administered for three days, resulting in five missed doses, due to complications in obtaining the medication from the pharmacy. Progress notes indicated staff were aware of the delay, but the medication was not delivered until several days after the order was written. Interviews with facility staff revealed that orders were not reviewed as required, and there was a lack of oversight in ensuring the medication was obtained and administered as prescribed. Staff also confirmed that when the Resident Care Manager was unavailable, other staff did not review new admission medications, contributing to the delay.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate and complete nurse staffing information as required, as evidenced by a review of Direct Care Staff Daily Reports from June 2025 through September 23, 2025. On 47 separate days, portions of the required staffing forms were either left blank or contained inaccurate information, including the daily census, the number of working staff, and staff hours worked. This deficiency was confirmed during an interview with the Administrator, who acknowledged the incomplete and inaccurate reports for the identified dates.
Failure to Re-Evaluate and Update Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to re-evaluate and update preventative interventions for a resident who developed multiple new pressure ulcers. The resident, who had a history of stroke with left-sided deficits, impaired mobility, incontinence, and other comorbidities, was identified as being at risk for skin integrity issues. Despite the care plan outlining several interventions such as frequent repositioning, offloading, and moisture management, the resident developed a superficial open area on the left buttock, moisture-associated skin damage to the coccyx, and an unstageable pressure wound to the heel over a period of several months. Record review and staff interviews revealed that there was no documented evidence of reassessment or modification of the care plan interventions after the development of new pressure ulcers. Nursing staff acknowledged that additional interventions should have been implemented but were not. Recommendations for interventions, such as a pressure-reducing air mattress, were made verbally but not documented or followed up. The lack of timely re-evaluation and implementation of new interventions contributed to the resident developing additional pressure ulcers.
Failure to Implement Airborne Precautions for TB Evaluation
Penalty
Summary
The facility failed to implement airborne precautions for a resident who was being evaluated for tuberculosis (TB). The resident was admitted with a history of cerebral infarction and, following a physician's order, received a TB test and subsequently had a chest x-ray ordered to rule out TB. An order for airborne precautions, including the use of N95 masks and keeping the resident's room door closed, was issued. However, the resident continued to participate in physical therapy and group sessions in communal areas without wearing a mask, and staff did not consistently use personal protective equipment (PPE) when entering the resident's room. The airborne precaution sign on the resident's door was handwritten and did not provide full instructions, and the door to the shared room was often left open with other residents present. Multiple staff members, including CNAs and LPNs, reported entering the resident's room and assisting the resident without PPE, and were unaware of any specialized infection control practices required. The resident confirmed that staff did not consistently wear PPE and that they were not instructed to wear PPE or sanitize hands when outside the room or during therapy. The Director of Nursing Services acknowledged that the airborne precautions were not fully implemented as required, and that staff were expected to follow these precautions until the chest x-ray results were received.
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