Inspection Reports for
Myrtle Point Rehabilitation and Care
637 Ash Street, Myrtle Point, OR, 97458
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
39.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
494% worse than Oregon average
Oregon average: 6.7 deficiencies/yearDeficiencies per year
120
90
60
30
0
Inspection Report
Complaint Investigation
Capacity: 35
Deficiencies: 2
Date: Dec 9, 2025
Visit Reason
No deficiencies found during this complaint and re-licensure survey.
Findings
No deficiencies found during this complaint and re-licensure survey.
Deficiencies (2)
F0000 - INITIAL COMMENTS
M0000 - Initial Comments
Inspection Report
Complaint Investigation
Capacity: 35
Deficiencies: 6
Date: Dec 8, 2025
Visit Reason
Multiple deficiencies related to resident privacy, abuse and neglect, reporting alleged violations, and administrative rules. None of the deficiencies were corrected at revisit.
Findings
Multiple deficiencies related to resident privacy, abuse and neglect, reporting alleged violations, and administrative rules. None of the deficiencies were corrected at revisit.
Deficiencies (6)
F0000 - INITIAL COMMENTS
F0583 - Personal Privacy/Confidentiality of Records
F0600 - Free from Abuse and Neglect
F0609 - Reporting of Alleged Violations
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 8, 2025
Visit Reason
The inspection was conducted following a complaint regarding failure to provide residents a private environment for physical intimacy and related abuse concerns involving two residents.
Complaint Details
The complaint involved allegations of inappropriate physical contact and failure to provide privacy for intimate relationships between two residents. The investigation found the incidents were consensual but privacy was not provided, sexual consent was not properly assessed, and abuse reporting was delayed beyond the required two-hour window.
Findings
The facility failed to provide a private place for residents to engage in intimate relationships, failed to assess a resident for sexual consent after an incident, and failed to timely report an allegation of abuse within the required two-hour timeframe.
Deficiencies (3)
F 0583: The facility failed to provide residents a private environment for physical intimacy for 2 of 4 sampled residents, placing them at risk for lack of privacy.
F 0600: The facility failed to ensure a resident was assessed for sexual consent after an incident, placing residents at risk for trauma.
F 0609: The facility failed to report an allegation of abuse within two hours for 1 of 4 sampled residents, placing residents at risk for ongoing abuse.
Report Facts
Residents sampled for abuse review: 4
Residents affected: 2
Hours delay in abuse reporting: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Administrator | Stated staff were to ensure residents were assessed after an incident to ensure safety and confirmed abuse reporting timeframes |
| Staff 2 | DNS | Stated there was no location designated for residents to meet privately for intimacy |
| Staff 3 | CNA | Observed the incident of physical contact and assisted residents back to the facility |
| Staff 4 | Charge Nurse | Acknowledged failure to assess consent timely and lack of awareness of abuse reporting requirements |
| Staff 11 | CNA | Worked night shift and was informed residents could be together only in private areas |
Inspection Report
Complaint Investigation
Capacity: 35
Deficiencies: 2
Date: Sep 19, 2025
Visit Reason
No deficiencies found during this complaint and re-licensure survey.
Findings
No deficiencies found during this complaint and re-licensure survey.
Deficiencies (2)
F0000 - INITIAL COMMENTS
M0000 - Initial Comments
Inspection Report
Complaint Investigation
Capacity: 35
Deficiencies: 21
Date: Nov 8, 2024
Visit Reason
Numerous deficiencies including failure to provide reasonable accommodations, safe environment, free from abuse and neglect, reporting alleged violations, ADL care, activities, quality of care, accident hazards, pain management, staffing, competency, pharmacy services, dental services, dietary services, resident records, payroll based journal, infection control, and administrative rules. Many deficiencies were corrected temporarily but not sustained.
Findings
Numerous deficiencies including failure to provide reasonable accommodations, safe environment, free from abuse and neglect, reporting alleged violations, ADL care, activities, quality of care, accident hazards, pain management, staffing, competency, pharmacy services, dental services, dietary services, resident records, payroll based journal, infection control, and administrative rules. Many deficiencies were corrected temporarily but not sustained.
Deficiencies (21)
F0000 - INITIAL COMMENTS
F0558 - Reasonable Accommodations Needs/Preferences
F0584 - Safe/Clean/Comfortable/Homelike Environment
F0600 - Free from Abuse and Neglect
F0609 - Reporting of Alleged Violations
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
F0677 - ADL Care Provided for Dependent Residents
F0679 - Activities Meet Interest/Needs Each Resident
F0684 - Quality of Care
F0689 - Free of Accident Hazards/Supervision/Devices
F0697 - Pain Management
F0725 - Sufficient Nursing Staff
F0726 - Competent Nursing Staff
F0730 - Nurse Aide Peform Review-12 hr/yr In-Service
F0755 - Pharmacy Srvcs/Procedures/Pharmacist/Records
F0791 - Routine/Emergency Dental Srvcs in NFs
F0801 - Qualified Dietary Staff
F0806 - Resident Allergies, Preferences, Substitutes
F0812 - Food Procurement,Store/Prepare/Serve-Sanitary
F0842 - Resident Records - Identifiable Information
Inspection Report
Complaint Investigation
Deficiencies: 21
Date: Nov 8, 2024
Visit Reason
The inspection was conducted in response to multiple public complaints alleging issues including inadequate wheelchair accommodations, failure to unpack residents' belongings, unclean environment, verbal abuse by staff, lack of supplies, failure to report and investigate abuse allegations, unmet ADL needs, lack of activities, medication mismanagement, staffing shortages, infection control lapses, and other regulatory concerns at the nursing home.
Complaint Details
The investigation was complaint-driven based on multiple public complaints received between 3/2024 and 11/2024 regarding inadequate wheelchair accommodations, failure to unpack belongings, unclean environment, verbal abuse, lack of supplies, failure to report abuse, unmet ADL needs, lack of activities, medication mismanagement, staffing shortages, infection control lapses, and other concerns.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs, inadequate environment and personal property care, verbal abuse and neglect, failure to report and investigate abuse, unmet assistance with ADLs, lack of activities, medication errors and delays, insufficient staffing, incomplete staff competencies and training, improper food handling and dietary management, incomplete medical records, failure to submit required staffing data, and inadequate infection control practices.
Deficiencies (21)
F 0558: The facility failed to reasonably accommodate the needs and preferences of residents, including failure to provide appropriate wheelchairs and assist with unpacking personal belongings for residents 8 and 14.
F 0584: The facility failed to provide a clean and homelike environment and ensure residents' belongings were safe, including unclean windows and disrepair of resident room windows.
F 0600: The facility failed to protect residents from verbal abuse by staff and neglect related to failure to provide needed supplies for residents 3, 14, 18, and 20.
F 0609: The facility failed to timely report allegations of abuse for resident 14, placing residents at risk for abuse.
F 0610: The facility failed to investigate an allegation of abuse for resident 14, placing residents at risk for abuse.
F 0677: The facility failed to ensure dependent residents received required assistance with ADLs, including resident 14 waiting up to an hour for care after activating call light.
F 0679: The facility failed to provide an ongoing activity program to meet residents' needs and failed to maintain a road-legal van for resident outings.
F 0684: The facility failed to respond to changes in condition and follow physician orders for residents 4 and 29, including delayed administration of Miralax and failure to timely assess choking resident.
F 0689: The facility failed to maintain an environment free from accident hazards and provide adequate supervision to prevent accidents, including unsafe wheelchair ramp and missing neurological assessments after falls.
F 0697: The facility failed to provide safe, appropriate pain management for resident 14 due to frequent missed or delayed pain medication doses.
F 0725: The facility failed to provide enough nursing staff to meet resident needs and have a licensed nurse in charge on each shift, with documented staffing shortages and inadequate response to call lights.
F 0726: The facility failed to ensure staff competencies for nursing assistants, lacking competency checklists for several CNAs.
F 0730: The facility failed to provide required annual CNA training and performance reviews for some staff.
F 0755: The facility failed to provide accurate and timely pharmaceutical services for resident 14, resulting in missed pain medication doses.
F 0791: The facility failed to provide or obtain dental services for resident 18, including failure to arrange follow-up dental treatment.
F 0801: The facility failed to employ a qualified dietary manager with required certification.
F 0806: The facility failed to ensure residents' food preferences were honored, including removal of alternative meal options and serving unappealing portions.
F 0812: The facility failed to ensure food was stored appropriately and discarded timely, with expired food items found in a resident refrigerator.
F 0842: The facility failed to safeguard resident-identifiable information and maintain complete medical records, including loss of tuberculosis testing records requiring retesting for residents 11 and 18.
F 0851: The facility failed to submit complete and accurate Payroll Based Journal staffing data for the third quarter of 2024.
F 0880: The facility failed to implement infection prevention and control standards for resident 27, including failure to place resident on precautions after readmission with MRSA infection.
Report Facts
Residents affected: 7
Residents affected: 5
Residents affected: 4
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents: 27
Days with staffing shortages: 38
Expired food items: 4
Days without BM: 5
Days delay in placing precautions: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff 20 | Former Administrator | Named in multiple findings including verbal abuse, staff terminations, and failure to report abuse |
| Staff 1 | Administrator | Named in findings related to staffing, abuse reporting, medication management, and dietary certification |
| Staff 2 | Interim DNS | Named in findings related to abuse reporting, medication management, staffing, and infection control |
| Staff 13 | CNA | Named in findings related to verbal abuse observation and ADL assistance |
| Staff 18 | CNA | Named in findings related to unpacking belongings, infection control, and meal portion observations |
| Staff 23 | Dietary Manager | Named in findings related to dietary certification and meal alternatives |
| Staff 9 | LPN | Named in findings related to neurological assessments and lost medical records |
| Staff 11 | Former LPN | Named in findings related to delayed resident assessment during choking incident |
| Staff 12 | Maintenance | Named in findings related to wheelchair ramp and facility van registration |
| Staff 15 | Central Supply | Named in findings related to supply shortages and delayed orders |
Inspection Report
Complaint Investigation
Deficiencies: 15
Date: Nov 8, 2024
Visit Reason
The inspection was conducted following multiple public complaints regarding resident care, staffing shortages, medication management, abuse allegations, environmental concerns, and infection control at Myrtle Point Rehabilitation & Care.
Complaint Details
The investigation was complaint-driven based on multiple public complaints received between March and August 2024 regarding abuse, neglect, staffing shortages, medication errors, environmental hazards, infection control breaches, and failure to provide adequate care and services.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs, inadequate environment and personal property safety, verbal abuse and neglect, failure to report and investigate abuse allegations, insufficient assistance with activities of daily living, lack of activities program, medication mismanagement, inadequate staffing, failure to maintain accident-free environment, improper pain management, failure to honor food preferences, incomplete medical records, and poor infection control practices.
Deficiencies (15)
F 0558: The facility failed to reasonably accommodate the needs and preferences of residents, including failure to provide appropriate wheelchair and assistive equipment and failure to assist with unpacking personal belongings for residents 8 and 14.
F 0584: The facility failed to provide a clean and homelike environment and ensure residents' belongings were safe for residents 18 and 19, including unclean windows and disrepair of a resident's window.
F 0600: The facility failed to protect residents from verbal abuse by staff and neglect related to failure to provide needed supplies for residents 3, 14, 18, and 20, including verbal abuse by Staff 20 and inadequate incontinent supplies.
F 0609: The facility failed to timely report allegations of abuse for resident 14, including verbal abuse by Staff 20 that was not reported to the State Survey Agency.
F 0610: The facility failed to investigate an allegation of abuse for resident 14, including lack of investigation into Staff 20's verbal abuse.
F 0677: The facility failed to ensure dependent residents received required assistance with activities of daily living for resident 14, including delayed response to call light and unmet needs.
F 0679: The facility failed to provide an ongoing activity program to meet residents' needs, with no activities available in July 2024 and an out-of-service facility van limiting outings.
F 0684: The facility failed to provide appropriate treatment and care according to orders and respond to changes in condition for residents 4 and 29, including failure to administer Miralax timely and delayed assessment of choking resident.
F 0689: The facility failed to maintain an environment free from accident hazards and provide adequate supervision to prevent accidents for residents 6 and 18, including unsafe wheelchair ramp and missing neurological assessments after falls.
F 0697: The facility failed to provide safe, appropriate pain management for resident 14, including multiple missed doses of Methadone and lack of physician notification.
F 0725: The facility failed to provide enough nursing staff to meet residents' needs, with documented staffing shortages and inadequate coverage for residents 14 and 18.
F 0755: The facility failed to provide required staff escort for resident 18 to medical appointments due to short staffing.
F 0806: The facility failed to ensure residents' food preferences were honored for resident 14, including removal of alternative meal menu and serving unappealing or insufficient food portions.
F 0842: The facility failed to safeguard resident-identifiable information and maintain complete medical records for residents 11 and 18, including loss of tuberculosis testing records requiring retesting.
F 0880: The facility failed to implement infection prevention and control standards for resident 27, including failure to place resident on precautions after readmission with MRSA infection.
Report Facts
Days with staffing below minimum CNA requirements: 30
Missed Methadone doses: 6
Days Resident 4 had no bowel movement: 5
Days delay in placing MRSA precautions: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff 20 | Former Administrator | Named in multiple findings related to verbal abuse, staff terminations, medication mismanagement, and staffing shortages. |
| Staff 1 | Administrator | Interviewed regarding expectations for abuse reporting, staffing, medication management, and infection control. |
| Staff 2 | Interim Director of Nursing Services | Interviewed regarding abuse reporting, medication management, staffing, and infection control. |
| Staff 13 | CNA | Witnessed verbal abuse by Staff 20 and involved in delayed assistance to Resident 14. |
| Staff 18 | CNA | Reported on Resident 14's discomfort with Staff 20 and meal portion concerns. |
| Staff 9 | LPN | Reported on missing neurological assessments and lost medical documents. |
| Staff 12 | Maintenance | Reported on wheelchair ramp and facility van registration issues. |
| Staff 23 | Dietary Manager | Reported on alternative meal menu removal and resident food preferences. |
| Staff 4 | CNA | Reported on incontinent supplies shortage and Resident 29 choking incident. |
| Staff 11 | Former LPN | Named in delayed response to Resident 29 choking and slow resident assessments. |
Inspection Report
Complaint Investigation
Capacity: 35
Deficiencies: 4
Date: Sep 19, 2024
Visit Reason
Deficiencies related to failure to timely obtain radiology services, initial comments, and administrative rules. Some deficiencies corrected but others not corrected at revisit.
Findings
Deficiencies related to failure to timely obtain radiology services, initial comments, and administrative rules. Some deficiencies corrected but others not corrected at revisit.
Deficiencies (4)
F0000 - INITIAL COMMENTS
F0776 - Radiology/Other Diagnostic Services
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 19, 2024
Visit Reason
The inspection was conducted in response to a public complaint alleging that Resident 300 did not receive a timely radiology appointment.
Complaint Details
A public complaint was received on 9/17/24 alleging Resident 300 did not receive a timely radiology appointment. The complaint was substantiated by interviews and record review.
Findings
The facility failed to timely obtain radiology services for Resident 300, resulting in a delay of approximately three months for a scheduled MRI appointment due to inaccurate documentation and lack of communication.
Deficiencies (1)
F 0776: The facility failed to provide timely, approved x-ray services or have an agreement with an approved provider to obtain them. Resident 300's MRI appointment was delayed from 6/19/24 to 9/11/24 due to missing physician signature and inaccurate documentation.
Report Facts
Delay duration: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Service Director | Acknowledged the delay in addressing Resident 300's physician order for radiology services |
Inspection Report
Complaint Investigation
Capacity: 35
Deficiencies: 4
Date: Sep 4, 2024
Visit Reason
Deficiencies related to abuse and neglect, initial comments, and administrative rules. Some deficiencies corrected but others not corrected at revisit.
Findings
Deficiencies related to abuse and neglect, initial comments, and administrative rules. Some deficiencies corrected but others not corrected at revisit.
Deficiencies (4)
F0000 - INITIAL COMMENTS
F0600 - Free from Abuse and Neglect
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 4, 2024
Visit Reason
The inspection was conducted to investigate a complaint regarding failure to follow care plan interventions to prevent physical abuse between residents.
Complaint Details
The complaint investigation found that Resident 1 struck Resident 2 on 7/23/23. Abuse was ruled out, but the facility acknowledged failure to follow Resident 1's care plan after a prior incident on 7/17/23.
Findings
The facility failed to follow Resident 1's care plan interventions, resulting in Resident 1 striking Resident 2 on the face. Abuse was ruled out, but the care plan was not followed after a prior incident.
Deficiencies (1)
F 0600: The facility failed to follow care plan interventions to protect residents from physical abuse, resulting in Resident 1 striking Resident 2. The investigation ruled out abuse but did not confirm adherence to care plan interventions.
Inspection Report
Capacity: 35
Deficiencies: 1
Date: Dec 26, 2023
Visit Reason
Deficiency related to failure to report complete COVID-19 information to CDC's NHSN during a required seven-day period.
Findings
Deficiency related to failure to report complete COVID-19 information to CDC's NHSN during a required seven-day period.
Deficiencies (1)
F0884 - Reporting - National Health Safety Network
Inspection Report
Deficiencies: 30
Date: Aug 2, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, nursing services, medication management, infection control, dietary services, and overall facility operations.
Findings
The facility was found deficient in multiple areas including failure to follow up on advance directives, medication management errors, inadequate environmental cleanliness, failure to address resident grievances, abuse prevention and investigation, staff hiring and training deficiencies, incomplete resident assessments and care plans, inadequate nursing coverage, failure to provide appropriate respiratory and dialysis care, and lack of effective quality assurance and infection control programs.
Deficiencies (30)
F578: Facility failed to follow up regarding advance directives for 3 sampled residents, risking residents' healthcare wishes not being honored.
F580: Facility failed to notify physician regarding medication refusals and errors for 1 sampled resident, risking lack of physician oversight.
F584: Facility failed to maintain a clean and homelike environment; observed stained and old carpets in hallways and resident rooms.
F585: Facility failed to provide written grievance resolution or communicate with resident regarding grievance for 1 sampled resident.
F600: Facility failed to protect residents from verbal and physical abuse and failed to thoroughly investigate abuse allegations for 2 sampled residents.
F606: Facility failed to ensure staff were employable for 1 staff member reviewed for personnel files, risking resident safety.
F607: Facility failed to implement abuse policies and failed to address abuse with QAPI committee for 2 sampled residents.
F609: Facility failed to timely report injury of unknown origin for 1 sampled resident reviewed for abuse.
F610: Facility failed to ensure thorough investigation for injury of unknown origin for 1 sampled resident reviewed for abuse.
F636: Facility failed to comprehensively assess 4 sampled residents, placing them at risk for unassessed needs.
F655: Facility failed to implement baseline care plan for 1 sampled resident reviewed for catheter care.
F656: Facility failed to develop and implement comprehensive care plans for 2 sampled residents reviewed for accidents and change of condition.
F677: Facility failed to ensure dependent residents received required assistance with activities of daily living for 1 sampled resident reviewed for UTI.
F684: Facility failed to timely respond to changes in condition and follow physician orders for 4 sampled residents, resulting in immediate jeopardy related to delayed treatment and hospitalization of Resident 129.
F689: Facility failed to provide safe and appropriate respiratory care according to physician orders for 3 sampled residents reviewed for respiratory services.
F690: Facility failed to provide essential dialysis-related assessment, care planning and monitoring for 1 sampled resident reviewed for dialysis, resulting in pain and extensive bruising.
F692: Facility failed to ensure adequate RN coverage for 64 of 81 days reviewed, risking lack of RN oversight.
F730: Facility failed to complete annual performance reviews for 4 of 5 CNA staff reviewed for staffing and abuse.
F758: Facility failed to ensure residents were free of unnecessary psychotropic medications for 2 sampled residents reviewed for unnecessary medications.
F801: Dietary Manager did not possess required certification to provide dietary manager services.
F806: Facility failed to ensure residents' food preferences were honored for 1 sampled resident reviewed for dietary preferences.
F812: Facility failed to serve food in a sanitary manner and maintain clean refrigerators and ice machine.
F835: Facility was not managed in a manner that enabled it to use resources effectively and efficiently, resulting in two immediate jeopardy situations and substandard quality of care.
F867: Facility failed to maintain an effective QAPI program with regular meetings and quality improvement activities.
F868: Facility failed to maintain a QAPI committee with required members and quarterly meetings.
F880: Facility failed to provide and implement an infection prevention and control program including sanitizing vital sign equipment and water management.
F881: Facility failed to implement an antibiotic stewardship program to monitor antibiotic use.
F883: Facility failed to assess immunization status and provide vaccines for 5 sampled residents reviewed for immunizations.
F940: Facility failed to have an effective training program for all new and existing staff members.
F947: Facility failed to ensure CNA staff completed required 12 hours annual training.
Report Facts
Days without RN coverage: 64
Weight loss percentage: 28
Medication administrations: 9
Fall dates without assessment: 2
Dialysis days attended: 3
Days without QAPI meeting: 365
Days without RN coverage in Oct 2022: 16
Days without RN coverage in Nov 2022: 12
Days without RN coverage in Mar 2023: 16
Days without RN coverage in Jul 2023: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff 34 | Social Service Director | Named in advance directive follow-up and grievance findings |
| Staff 3 | Clinical Operations Education Director | Named in multiple findings including medication errors, care planning, respiratory care, dialysis, QAPI |
| Staff 1 | Administrator | Named in findings related to RN coverage, QAPI, personnel files |
| Staff 2 | Director of Nursing Services (DNS) | Named in findings related to abuse, RN coverage, infection control, antibiotic stewardship, QAPI |
| Staff 10 | Former CNA | Named in verbal abuse finding and personnel file missing |
| Staff 26 | LPN | Named in medication administration and dialysis care findings |
| Staff 27 | Former LPN | Named in fall assessment findings |
| Staff 12 | Dietary Manager | Named in dietary certification and food preference findings |
| Staff 5 | LPN | Named in fall and dialysis care findings |
| Staff 6 | CNA | Named in staff training and infection control findings |
| Staff 20 | CNA | Named in dialysis transport and fall investigation findings |
| Staff 3 | Regional Director of Operations | Named in QAPI and RN coverage findings |
Inspection Report
Complaint Investigation
Capacity: 35
Deficiencies: 41
Date: Aug 2, 2023
Visit Reason
Multiple deficiencies including failure to follow up on advance directives, notify of changes, maintain clean environment, grievance resolution, abuse prevention, comprehensive assessments, quality of care, staffing, dietary services, transfer agreements, hospice services, QAPI program, infection control, antibiotic stewardship, immunizations, training requirements, and administrative rules. Many deficiencies were not corrected at revisit.
Findings
Multiple deficiencies including failure to follow up on advance directives, notify of changes, maintain clean environment, grievance resolution, abuse prevention, comprehensive assessments, quality of care, staffing, dietary services, transfer agreements, hospice services, QAPI program, infection control, antibiotic stewardship, immunizations, training requirements, and administrative rules. Many deficiencies were not corrected at revisit.
Deficiencies (41)
F0000 - INITIAL COMMENTS
F0578 - Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir
F0580 - Notify of Changes (Injury/Decline/Room, etc.)
F0584 - Safe/Clean/Comfortable/Homelike Environment
F0585 - Grievances
F0600 - Free from Abuse and Neglect
F0606 - Not Employ/Engage Staff w/ Adverse Actions
F0607 - Develop/Implement Abuse/Neglect Policies
F0609 - Reporting of Alleged Violations
F0610 - Investigate/Prevent/Correct Alleged Violation
F0636 - Comprehensive Assessments & Timing
F0655 - Baseline Care Plan
F0656 - Develop/Implement Comprehensive Care Plan
F0657 - Care Plan Timing and Revision
F0677 - ADL Care Provided for Dependent Residents
F0684 - Quality of Care
F0689 - Free of Accident Hazards/Supervision/Devices
F0697 - Pain Management
F0725 - Sufficient Nursing Staff
F0726 - Competent Nursing Staff
F0730 - Nurse Aide Peform Review-12 hr/yr In-Service
F0755 - Pharmacy Srvcs/Procedures/Pharmacist/Records
F0791 - Routine/Emergency Dental Srvcs in NFs
F0801 - Qualified Dietary Staff
F0806 - Resident Allergies, Preferences, Substitutes
F0812 - Food Procurement,Store/Prepare/Serve-Sanitary
F0835 - Administration
F0842 - Resident Records - Identifiable Information
F0843 - Transfer Agreement
F0849 - Hospice Services
F0865 - QAPI Prgm/Plan, Disclosure/Good Faith Attmpt
F0867 - QAPI/QAA Improvement Activities
F0868 - QAA Committee
F0880 - Infection Prevention & Control
F0881 - Antibiotic Stewardship Program
F0883 - Influenza and Pneumococcal Immunizations
F0940 - Training Requirements
F0947 - Required In-Service Training for Nurse Aides
M0000 - Initial Comments
M0182 - Nursing Services:Minimum Licensed Nurse Staff
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Inspection Report
Complaint Investigation
Deficiencies: 24
Date: Aug 2, 2023
Visit Reason
The inspection was conducted based on complaints and allegations related to resident grievances, abuse, neglect, care planning, medication administration, falls, respiratory care, and other quality of care concerns.
Complaint Details
The complaint investigation revealed multiple deficiencies including failure to address grievances, prevent abuse, conduct comprehensive assessments, follow physician orders, provide adequate nursing coverage, maintain nutritional and respiratory care, conduct physician visits, maintain accurate records, and maintain effective QAPI and training programs. Immediate jeopardy was identified related to failure to timely respond to changes in condition and follow physician orders for several residents.
Findings
The facility was found deficient in multiple areas including failure to address resident grievances, prevent verbal and physical abuse, ensure employable staff, implement abuse policies, timely report suspected abuse, conduct comprehensive assessments, develop and update care plans, follow physician orders, provide adequate nursing coverage, maintain nutritional and respiratory care, conduct physician visits as required, maintain accurate resident records, and maintain an effective QAPI program. Immediate jeopardy was identified related to failure to timely respond to changes in condition and follow physician orders for several residents.
Deficiencies (24)
F0585: The facility failed to provide a written grievance resolution or communicate with a resident regarding the resolution of a grievance for 1 sampled resident.
F0600: The facility failed to protect residents from verbal abuse by staff and physical abuse by a resident for 2 sampled residents.
F0606: The facility failed to ensure staff were employable for 1 staff member reviewed for personnel files.
F0607: The facility failed to implement abuse policies and failed to address abuse with the QAPI committee for 2 sampled residents.
F0609: The facility failed to timely report an injury of unknown origin for 1 sampled resident reviewed for abuse.
F0610: The facility failed to ensure a thorough investigation was completed for an injury of unknown origin for 1 sampled resident.
F0636: The facility failed to comprehensively assess 4 sampled residents reviewed for medications and nutrition.
F0656: The facility failed to develop and implement comprehensive care plans for 2 sampled residents reviewed for accidents and change of condition.
F0657: The facility failed to update care plans for 2 sampled residents reviewed for accidents and UTIs.
F0684: The facility failed to timely respond to changes in condition and follow physician orders for 4 sampled residents, resulting in immediate jeopardy.
F0689: The facility failed to provide adequate supervision to prevent accidents and failed to implement fall risk interventions for 2 sampled residents.
F0692: The facility failed to maintain healthy nutritional status and honor food preferences for 1 sampled resident.
F0695: The facility failed to provide respiratory care and services in accordance with physician orders for 3 sampled residents.
F0712: The facility failed to ensure residents were seen as required by a physician for 2 sampled residents.
F0727: The facility failed to ensure an RN worked as the charge nurse for eight consecutive hours per day for 64 of 81 days reviewed.
F0730: The facility failed to ensure staff annual performance reviews were completed for 4 CNA staff reviewed.
F0806: The facility failed to ensure residents' food preferences were honored for 1 sampled resident.
F0835: The facility was not managed in a manner that enabled it to use its resources effectively and efficiently, resulting in two immediate jeopardy situations and substandard quality of care.
F0842: The facility failed to ensure resident records were complete and accurate for 3 sampled residents reviewed for change of condition, dialysis and medications.
F0849: The facility failed to ensure a hospice agreement was in place with a hospice provider for 1 sampled resident receiving hospice services.
F0865: The facility failed to develop a Quality Assessment and Assurance program that identified quality deficiencies and implemented corrective action plans.
F0867: The facility failed to have a Quality Assessment and Assurance committee that met and included required members.
F0940: The facility failed to have an effective training program for staff related to Resident Rights, Abuse, Neglect, QAPI and Infection Control.
F0947: The facility failed to ensure CNA staff completed the required 12 hours annual training.
Report Facts
Days without RN coverage: 64
Weight loss percentage: 28
Resident weight: 158
Resident weight: 114
Oxygen flow rate: 2.5
Oxygen flow rate: 1.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Administrator | Confirmed lack of RN coverage and missing personnel files. |
| Staff 2 | Director of Nursing (DNS) | Acknowledged multiple deficiencies including abuse investigations, RN coverage, and QAPI issues. |
| Staff 3 | Clinical Operations Education Director | Confirmed lack of staff training, incomplete care plans, and missing physician visits. |
| Staff 6 | CNA | Interviewed regarding training hours and abuse incident. |
| Staff 10 | Former CNA | Involved in verbal abuse incident and personnel file missing. |
| Staff 12 | Dietary Manager | Unable to locate food preference assessment for Resident 129. |
| Staff 20 | CNA | Reported lack of RN coverage and fall incident follow-up. |
| Staff 27 | Former LPN | Acknowledged failure to document assessments after resident fall. |
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Sep 10, 2022
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care, including resident rights, care planning, medication administration, activities, and facility services.
Findings
The facility was found deficient in multiple areas including failure to provide advance directive education, incomplete resident assessments, inadequate care plans for mobility and medical devices, improper medication administration practices, insufficient nail care, lack of resident activities, failure to provide adequate range of motion services, absence of required face-to-face physician visits, unqualified dietary management staff, and poor food quality and temperature.
Deficiencies (10)
F 0578: The facility failed to provide advance directive education, assistance, and follow-up for 3 sampled residents, placing them at risk of being uninformed regarding medical decisions.
F 0636: The facility failed to comprehensively assess 2 sampled residents for positioning and mobility, resulting in unmet needs.
F 0656: The facility failed to develop comprehensive person-centered care plans for 2 sampled residents regarding positioning, mobility, and medical devices, placing residents at risk for unmet needs.
F 0658: Facility staff failed to ensure adherence to professional standards in insulin administration, dignity, and medication administration for 2 sampled residents, risking adverse side effects.
F 0677: The facility failed to provide nail care for 1 sampled resident, resulting in long, dirty fingernails and toenails.
F 0679: The facility failed to provide an ongoing program of activities to meet residents' interests and physical, mental, and psychosocial needs, with no activities observed during the survey period.
F 0688: The facility failed to provide adequate range of motion exercises or restorative assistance services for 4 sampled residents with limited range of motion, risking decreased mobility.
F 0712: The facility failed to ensure residents received required in-person, onsite physician visits, as the contractor did not come into the facility.
F 0801: The Dietary Manager did not possess the required certification to provide dietary management services, placing residents at risk for unmet dietary needs.
F 0804: The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature, with residents reporting poor taste, rubbery eggs, cold food, and repetitive menus.
Report Facts
Residents affected: 3
Residents affected: 2
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff 10 | Social Service Director | Named in advance directive education deficiency |
| Staff 2 | Director of Nursing Services (DNS) | Acknowledged multiple deficiencies including advance directives, assessments, care plans, medication administration, range of motion, and physician visits |
| Staff 3 | RN Care Manager (RNCM) | Acknowledged incomplete assessments and care plans |
| Staff 7 | Registered Nurse (RN) | Observed administering insulin improperly |
| Staff 9 | Certified Nursing Assistant (CNA) | Observed nail care and contracture care deficiencies |
| Staff 16 | Activities Director | Reported lack of activities and no dedicated activity room |
| Staff 4 | Dietary Manager | Did not possess required dietary management certification |
| Staff 1 | Administrator | Acknowledged dietary management certification deficiency and food quality concerns |
Inspection Report
Re-licensure
Capacity: 35
Deficiencies: 12
Date: Sep 10, 2022
Visit Reason
Deficiencies related to advance directives, comprehensive assessments, care plans, professional standards, ADL care, activities, physician visits, dietary services, and administrative rules. Some deficiencies corrected but others not corrected at revisit.
Findings
Deficiencies related to advance directives, comprehensive assessments, care plans, professional standards, ADL care, activities, physician visits, dietary services, and administrative rules. Some deficiencies corrected but others not corrected at revisit.
Deficiencies (12)
F0000 - INITIAL COMMENTS
F0578 - Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir
F0636 - Comprehensive Assessments & Timing
F0656 - Develop/Implement Comprehensive Care Plan
F0658 - Services Provided Meet Professional Standards
F0677 - ADL Care Provided for Dependent Residents
F0679 - Activities Meet Interest/Needs Each Resident
F0712 - Physician Visits-Frequency/Timeliness/Alt NPP
F0801 - Qualified Dietary Staff
M0000 - Initial Comments
M0320 - Dietary Services: Diets and Menus
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Inspection Report
State Licensure
Capacity: 35
Deficiencies: 1
Date: Sep 21, 2021
Visit Reason
No deficiencies found during this state licensure survey.
Findings
No deficiencies found during this state licensure survey.
Deficiencies (1)
M0000 - Initial Comments
Viewing
Loading inspection reports...
