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 sepsis, pneumonia, and acute respiratory failure, who was cognitively intact but dependent for wheelchair mobility, was assisted back to their room after dinner and left alone in a wheelchair while staff sought a second person for a two-person transfer. Staff did not return for over an hour, and the resident reported being alone for more than an hour without a call light or phone within reach, experiencing pain and being unable to transfer or move the wheelchair independently. A CNA assigned to both the resident and dining room duties stated she could not leave the dining room and had asked another CNA to assist, later finding the resident still waiting in the wheelchair, and facility leadership acknowledged the transfer assistance was not provided in a timely manner.
A resident with a right lower leg fracture and intact cognition had a STAT physician order for Lokelma to treat elevated potassium, but the facility failed to administer the medication as ordered. The missed STAT dose was identified in facility documentation, and the on-call provider was notified, after which the resident was sent to the ER. A hospital social worker confirmed the medication was not given and that the transfer was related to the missed dose. An LPN and an RN/RCM both recalled a medication error involving Lokelma, and facility leadership acknowledged the resident should have received the STAT medication.
Surveyors found that a hallway water dispenser had visible buildup on both hot and cold outlets, with no established cleaning schedule or documentation for regular outlet sanitation. Housekeeping staff reported they only cleaned the exterior of the dispenser, and maintenance staff confirmed there was no routine process for cleaning the outlets. In addition, a resident snack refrigerator contained three unlabeled pitchers of red and yellow liquids, with an LPN confirming the lack of labels and the dietary manager acknowledging that these beverages should have been dated. The administrator stated he expected staff to perform required job duties.
A resident with a Stage 4 sacral pressure ulcer and intact cognition returned from a wound clinic with an order from an NP for wheelchair seat mapping to obtain a new cushion after a prior Roho cushion had been removed. Facility staff documented the order and faxed it to a vendor, but the fax was sent to an incorrect number, and the seat mapping was neither timely ordered nor completed. Follow-up notes showed that when staff later contacted the vendor, the vendor reported not receiving the fax and requested the order again, leading to prolonged delays in scheduling the seat mapping and failure to carry out the physician’s wound care-related order.
Surveyors identified unsanitary conditions in the laundry room, including a longstanding hole in the wall near washing machines, brown standing water behind the machines, and a black substance along the wall and floor. The housekeeping director reported that maintenance had been notified weeks earlier but repairs had not been made and could not identify the black substance. A cart of clean linen was placed near the standing water, and a blanket was observed partially submerged in the dirty water, which a laundry aide confirmed. The administrator later verified the standing water and black substance and was informed that water had been leaking onto the floor whenever the machines were used for several weeks.
A cognitively intact resident with heart failure and kidney disease reported that a CNA/CMA spoke meanly, was rough, and treated them like a “bad dog,” and expressed fear of retaliation and discharge. An LPN acknowledged hearing this CNA/CMA be rude to the resident and to others, and stated that other staff had observed similar behavior, but she did not report it to management. The Administrator and DNS were later informed of the allegation and stated that staff are expected to notify them, the provider, and family when a resident feels abused, yet the allegation was not reported to the State Survey Agency as required.
Two residents experienced deficiencies in accident prevention when staff did not follow their care plans. One resident with dementia and a history of rolling out of bed was repeatedly observed in bed without a required fall mat properly placed on one side, despite a care plan directing padded mats on both sides whenever the resident was in bed. Another resident with stroke-related weakness, care planned for two-person assistance with transfers using a FWW, was transferred by a single CNA after a shower without reviewing the care plan, during which the resident’s legs weakened and the resident slid or fell to the floor. Staff and leadership later confirmed that both residents were care planned for these specific safety measures and that staff were expected to follow and review care plans.
The facility did not maintain required RN coverage for at least eight consecutive hours per day on multiple days, as shown by review of Direct Care Staff Daily Reports over several months. Staff reported that the RN manager was only recently added to the staffing report, and the Administrator stated that staff were expected to call off two hours before their shift to allow time to find coverage. When surveyors requested payroll records to verify RN presence on the identified days, no additional documentation was provided, resulting in a cited deficiency for inadequate RN staffing.
Two residents experienced multiple room changes without receiving the written advance notice required by facility policy, which mandates written notification with reasons for any room or roommate change. One resident with quadriplegia and aphasia had a designated family responsible party who was not given written notice before a room move, as confirmed by both the family member and facility leadership. Another resident with dementia and cognitive communication deficits underwent several room changes, with no documentation of written notification in the clinical record, and the Administrator acknowledged that written notices were not provided in these instances.
Two dependent residents did not receive scheduled showers needed to maintain hygiene and dignity. One resident with quadriplegia, aphasia, and severe cognitive impairment was care planned for staff-assisted showers but, over multiple scheduled opportunities, received only a few showers, some bed baths, and no documented make-up showers for several missed or refused shower days, despite family complaints of strong body odor and greasy hair and staff acknowledgment that showers were important. Another resident with diabetes, metabolic encephalopathy, and bowel and bladder incontinence, who preferred showers and was scheduled for twice-weekly bathing, had only one shower documented over about a month, with no evidence of additional offers when showers were missed. Staff interviews revealed that residents rarely refused showers, that agency CNAs frequently documented refusals without offering showers, and that heavy reliance on agency staff and workload issues, especially on evening and weekend shifts, led to showers not being completed as scheduled.
Failure to Provide Timely Transfer Assistance and Access to Call System
Penalty
Summary
The deficiency involves the facility’s failure to provide timely transfer assistance to a resident who required staff support for activities of daily living. The resident was admitted with sepsis, lobar pneumonia, and acute respiratory failure with hypoxia, and the admission MDS documented a BIMS score of 14, indicating the resident was cognitively intact but dependent for wheelchair mobility. A nursing care note documented that after dinner the resident was assisted back to their room and left alone in a wheelchair while staff went to obtain a second person for a two-person transfer. Staff did not return to the room for over an hour. A risk management report completed by an LPN confirmed the resident remained alone in the wheelchair in the room for over an hour awaiting transfer assistance. The resident later stated they were left alone for approximately one hour and ten minutes, did not have a call light or phone within reach, experienced pain, and were unable to transfer or move the wheelchair independently. A CNA reported being assigned both to the resident and to dining room duties and stated she could not leave the dining room while residents were still eating, so she requested another CNA to assist the resident back to the room; she later found the resident still sitting alone in the wheelchair awaiting transfer to bed. Multiple facility leaders, including the assistant administrator in training, field lead, chief nursing officer, and assistant chief nursing officer, acknowledged the resident should have received more timely transfer assistance.
Failure to Administer STAT-Ordered Lokelma for Elevated Potassium
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s STAT medication order for a resident with an elevated potassium level. The resident was admitted with a diagnosis of a right lower leg fracture and had a BIMS score of 13, indicating intact cognition. A STAT order for Lokelma, a medication used to treat high blood potassium levels, was placed on 8/1/25. According to the facility’s Risk Management report and a Progress Note dated 8/3/25, the facility did not administer the ordered STAT dose of Lokelma. As a result of the missed medication, the on-call provider was notified and the resident was sent to the emergency room on 8/3/25. During interviews, a hospital social worker stated the facility failed to administer the physician-ordered medication for the resident’s elevated potassium level and confirmed the resident was sent to the hospital related to the missed dose. An LPN reported that a medication error occurred involving the Lokelma dose and stated that an incident report should have been written, though they could not recall if one was completed. An RN/Resident Care Manager also recalled a medication error involving the Lokelma but could not remember details of the findings. Administrative and nursing leadership staff acknowledged that the resident should have received the STAT Lokelma dose as ordered.
Improper Maintenance of Water Dispenser and Unlabeled Beverages in Resident Snack Refrigerator
Penalty
Summary
The facility failed to ensure that a hallway water dispenser was maintained and sanitized in accordance with professional standards. A public complaint was received alleging that filtered water stations had pink slime and were not replaced or cleaned. During observation, the water dispenser across from the main nurses' station was found with an orangish buildup on the cold-water outlet and a gray to black buildup on the hot-water outlet. An LPN confirmed the buildup on both outlets. The housekeeping manager stated that housekeeping was responsible only for cleaning and sanitizing the outside of the dispenser, not the outlets or the inside. The maintenance director reported there was no cleaning schedule or documentation showing that the water dispenser outlets were regularly cleaned. The administrator stated he expected staff to complete the necessary activities for their job as required. The facility also failed to ensure that drinks stored in a resident snack refrigerator were labeled in accordance with professional standards. During observation, three clear pitchers containing red and yellow liquids were found in the resident snack refrigerator without any labels indicating when they were placed there or when they should be removed. The LPN confirmed the pitchers were not labeled. The dietary manager confirmed that the pitchers of juice in the resident snack refrigerator should have date labels. The administrator again stated he expected staff to complete the necessary activities for their job as required.
Failure to Follow Physician Orders for Wheelchair Seat Mapping for Pressure Ulcer Management
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for wound care interventions for one cognitively intact resident with a Stage 4 sacral pressure ulcer and a history of stroke. The resident was evaluated in a wound ostomy clinic, where the nurse practitioner documented that the resident’s wound healing had stalled and ordered a wheelchair seat mapping to obtain an appropriate new wheelchair cushion after a previously ordered Roho cushion had been removed from use. The order specified that the facility should schedule the seat mapping appointment, and a progress note documented that the resident returned from wound care with this new order related to the sacral pressure injury. The order was faxed to a vendor the same day. Despite this, subsequent documentation showed that the seat mapping was not timely ordered or completed. Two days after the order, the nurse practitioner confirmed that the seat mapping had still not been ordered or completed. Weeks later, a nurse’s progress note indicated that when staff called the vendor for an update, the vendor reported they needed the order faxed, and a later note documented that the vendor had not received any faxes from the facility. It was confirmed that the facility had faxed the order to an incorrect fax number. Additional information from the DNS indicated that the referral had to be re-faxed months later and that there were ongoing unsuccessful attempts at communication with the vendor, resulting in a significant delay between the original order and the scheduling of the seat mapping appointment. This sequence of events reflects the facility’s failure to ensure timely and accurate coordination and follow-through on the physician’s order for wheelchair seat mapping for the resident’s pressure ulcer management.
Unsanitary Laundry Room Conditions and Contaminated Clean Linen
Penalty
Summary
The facility failed to ensure laundry was cleaned and sorted in a safe manner when surveyors observed a hole in the wall next to the washing machine and a large pool of brown, dirty standing water behind two washing machines and a clean linen cart in the laundry room. Along the baseboard of the wall behind the machines, a black substance extended about an inch up the wall and an inch onto the floor. The Housekeeping Director stated the hole in the wall had been present for some time, that maintenance had been notified of the standing water a few weeks earlier but it had not yet been repaired, and did not know what the black substance was. Later observation showed a cart of clean linen and laundry near the standing water, with a blanket from the cart partially in the water, which the Laundry Aide confirmed had touched the water. The Administrator subsequently confirmed the presence of standing water and the black substance on the wall and floor and learned from the Laundry Aide that the water on the floor had been occurring for the last three weeks when the washing machines were in use, and that the water and some of the black substance had just been cleaned up. No specific residents or their medical conditions were mentioned in the report.
Failure to Report Resident’s Abuse Allegation to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse and neglect to the State Survey Agency for one cognitively intact resident. The resident, admitted with diagnoses including heart failure and kidney disease, had a care plan dated 12/24/25 indicating that if the resident made accusatory comments about family or staff not treating them well or denying medications, staff were to alert the nurse to assess for signs and symptoms of a urinary tract infection. On 1/12/26 at 2:13 PM, the resident reported that a CNA/CMA had abused them, stating the staff member spoke meanly, was rough, and treated them like a “bad dog.” The resident also expressed fear of retaliation from the staff member and fear of being discharged from the facility. At 2:16 PM the same day, an LPN stated that the staff member identified by the resident was a CNA/CMA and acknowledged hearing this staff member be rude to the resident. The LPN further reported that this staff member’s demeanor changed when rushed or having a bad day and that she had heard the staff member be rude to other residents, with other staff also observing this behavior, but she did not report it to management. At 2:42 PM, the Administrator and DNS were notified that the resident felt abused by this staff member, and the Administrator indicated this was the first time he had heard of the allegation. At 2:52 PM, the Administrator and DNS stated their expectation that when a resident feels abused by a staff member, staff must notify them immediately, notify the provider and family, and ensure resident safety; however, the allegation had not been reported to the State Survey Agency as required.
Failure to Follow Care Plans for Fall Mats and Two-Person Transfers
Penalty
Summary
Surveyors identified that the facility did not consistently follow an established fall-prevention care plan for a resident with dementia and a history of rolling out of bed. The resident’s care plan, initiated in early December, required padded fall mats on both sides of the bed whenever the resident was in bed. On multiple observations over several days in January, the resident was seen in bed without a fall mat on the left side, or with the left fall mat placed away from the bedside or folded and leaning against the foot of the bed. A CNA confirmed the resident was at risk for falls and should have fall mats on the floor next to the bed while in bed, and a LPN Resident Care Manager stated the resident had previously rolled out of bed and was care planned for fall mats on both sides, with the expectation that staff follow the care plan. Surveyors also found that staff failed to follow a care plan requiring two-person assistance for transfers for a resident with a history of stroke and weakness. The resident’s care plan documented a need for two-person assistance with transfers using a front-wheeled walker. A fall investigation from July showed that a CNA, after providing a shower, assisted the resident to stand and transfer using the walker without a second staff member, during which the resident’s legs weakened, balance was lost, and the resident slid or fell to the floor. The CNA stated she did not review the care plan before performing the transfer, and the investigation and root cause analysis identified that the resident was a two-person assist and the CNA did not check the care plan. The LPN notified of the incident and facility leadership later acknowledged that the resident was care planned as a two-person transfer and that staff were expected to review the care plan before providing care.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to provide RN coverage for eight consecutive hours per day, seven days per week, as required, on 21 of 78 reviewed days between August and November 2025. Review of the Direct Care Staff Daily Reports for 8/2025, 9/2025, 10/2025, and 11/2025 showed that on multiple specific dates in each of those months there was no RN documented as being on duty for the required eight-hour period. Staff interviews revealed that staff were only instructed to begin reporting the RN manager on the Direct Care Staff Daily Report starting 1/13/25, and the Administrator stated that staff were expected to call off work two hours before their shift to allow time to find coverage. Surveyors requested payroll documentation to verify RN work on the identified dates, but no additional documentation was provided, and the deficiency was cited as placing residents at risk for unmet assessment needs. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency was based on staffing records, staff interviews, and the absence of corroborating payroll documentation for RN coverage on the listed dates.
Failure to Provide Required Written Notice of Room Changes
Penalty
Summary
The deficiency involves the facility’s failure to provide written advance notice of room changes to residents or their responsible parties, as required by the facility’s Room/Roommate and Change Notification Policy dated 8/1/24. That policy states residents have the right to receive written notice, including the reason for the change, before a room or roommate change occurs. For one resident admitted in 7/2025 with quadriplegia and aphasia, the admission profile/face sheet identified a family member as the responsible party. The clinical record showed this resident was moved to a different room on 8/21/25, but progress notes from 7/2025 through 9/2025 contained no documentation that written notification of the room change was provided to the responsible family member. During interview, the family member stated she did not receive written notification before the move, and the DNS and Administrator confirmed that no written notification had been provided. A second resident, admitted in 2/2025 with dementia and cognitive communication deficits, was identified as their own responsible party. The census showed this resident had multiple room changes on 12/20/25, 12/22/25, 12/30/25, and 1/3/26. On interview, the resident’s communication was unintelligible and responses unreliable when asked about the room changes. Review of the clinical record revealed no documentation of written notification for any of these room changes. The Administrator reported that residents or their responsible parties should receive written notification of room changes prior to being moved and confirmed that no written notifications were provided for this resident’s room changes.
Failure to Provide Scheduled Showers and Hygiene Care for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure dependent residents received showers as needed to maintain personal hygiene and dignity, contrary to its Activities of Daily Living policy requiring necessary services for grooming and hygiene. One resident with quadriplegia, aphasia, severe cognitive deficit, and total dependence for bathing was care planned to receive one-person total assistance for showers, but the care plan did not specify shower frequency. Bathing task logs for a one‑month period showed this resident was scheduled for showers twice weekly on Wednesdays and Saturdays, with 10 shower opportunities. The resident received showers on only four of those dates, two bed baths on two dates, and had no documented showers or make‑up showers on three Saturdays and one additional date when a shower was refused. There was no evidence in the clinical record that missed showers were made up, and a family grievance documented concerns about strong body odor and greasy hair and face, as well as a request to increase shower frequency. Interviews with CNAs and nursing staff confirmed that the resident was dependent on staff for showering, usually did not refuse showers, and that the expected practice was to make up missed showers later the same day or the next day, and to offer a bed bath if a shower was refused. Staff reported that showers were important for this resident due to sweating, smelly hair, and oily skin. Staff also acknowledged that showers were not consistently completed, particularly on Saturdays, and attributed this to heavy reliance on agency CNAs. The Assistant DNS/Resident Care Manager and DNS were aware that scheduled showers were missed during the review period, and observations over several days showed the resident in bed or in a Geri chair with oily facial skin. A second resident with diabetes, metabolic encephalopathy, bowel and bladder incontinence, and total dependence on staff for bathing was care planned to receive showers twice weekly and as necessary, with a preference for showers. The shower schedule listed this resident for Wednesday and Saturday evening showers, but bathing task logs over a one‑month period showed only one documented shower. Progress notes contained no evidence of additional shower opportunities when showers were refused or not provided. During observations, the resident was noted in bed with greasy hair and wearing a gown, and reported not being showered regularly, estimating the last shower was about a month prior, and stating that staff had not offered showers in a long time and that refusals were rare. CNAs confirmed the resident was frequently soiled, rarely refused showers, and that agency CNAs often documented refusals without actually offering showers. Staff also reported that scheduled showers were often not completed due to workload, staffing patterns, and the need for two staff and a mechanical lift for this resident, and the DNS and regional clinical leader confirmed that the last documented shower date for this resident was not acceptable.
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