Inspection Reports for Nehalem Valley Care Center
280 Rowe Street, OR, 97147
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Inspection Report
Complaint Investigation
Capacity: 50
Deficiencies: 38
Aug 29, 2025
Visit Reason
State-compiled facility profile showing 10 inspections from 2022 to 2025 with detailed deficiency history and enforcement findings.
Findings
Across multiple inspections from 2022 to 2025, the facility exhibited numerous deficiencies including insufficient nursing and CNA staffing, failure to follow infection prevention protocols, inadequate medication administration, poor environmental conditions, and incomplete investigations of abuse allegations. Deficiencies placed residents at risk for unmet care needs, infection, medication errors, and diminished quality of life.
Complaint Details
Multiple complaint investigations documented including failure to report abuse allegations timely, failure to conduct thorough abuse investigations, and multiple complaints regarding staffing shortages and resident care.
Deficiencies (38)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| F0550 - Resident Rights/Exercise of Rights: Failed to ensure dignified dining experience and proper resident rights. |
| F0605 - Right to be Free from Chemical Restraints: Failed to ensure residents free from unnecessary antipsychotic medication use. |
| F0725 - Sufficient Nursing Staff: Failed to ensure sufficient nursing staff to meet resident care needs timely. |
| F0727 - RN 8 Hrs/7 days/Wk, Full Time DON: Failed to ensure RN coverage for eight consecutive hours per day and full-time Director of Nursing. |
| F0804 - Nutritive Value/Appear, Palatable/Prefer Temp: Failed to prepare pureed foods conserving nutritive value and flavor. |
| F0880 - Infection Prevention & Control: Failed to ensure proper hand hygiene and PPE use for contact precautions. |
| M0000 - Initial Comments |
| M9999 - STATE OF OREGON ADMINISTRATIVE RULES: Refer to multiple cited deficiencies. |
| F0582 - Medicaid/Medicare Coverage/Liability Notice: Failed to provide required liability notices with start date of financial liability. |
| F0609 - Reporting of Alleged Violations: Failed to report abuse allegation within mandated timeframe. |
| F0610 - Investigate/Prevent/Correct Alleged Violation: Failed to conduct thorough abuse investigations. |
| F0623 - Notice Requirements Before Transfer/Discharge: Failed to provide written notice after emergent transfer. |
| F0625 - Notice of Bed Hold Policy Before/Upon Trnsfr: Failed to provide written bed hold notice at time of transfer. |
| F0641 - Accuracy of Assessments: Failed to ensure accurate MDS data for pressure injury staging. |
| F0658 - Services Provided Meet Professional Standards: Failed to adhere to medication preparation and administration standards. |
| F0684 - Quality of Care: Failed to provide care and services in accordance with professional standards including bowel care and medication administration. |
| F0689 - Free of Accident Hazards/Supervision/Devices: Failed to ensure adequate supervision and accident hazard prevention. |
| F0690 - Bowel/Bladder Incontinence, Catheter, UTI: Failed to provide appropriate catheter care and use of lidocaine jelly. |
| F0726 - Competent Nursing Staff: Failed to ensure mandatory training and competencies for agency staff. |
| F0758 - Free from Unnec Psychotropic Meds/PRN Use: Failed to monitor individualized expressions of depression for psychotropic medication use. |
| F0759 - Free of Medication Error Rts 5 Prcnt or More: Medication administration errors identified exceeding 5% error rate. |
| F0801 - Qualified Dietary Staff: Failed to ensure dietary manager met required qualifications. |
| F0812 - Food Procurement,Store/Prepare/Serve-Sanitary: Failed to maintain sanitary food storage and preparation conditions. |
| F0908 - Essential Equipment, Safe Operating Condition: Failed to maintain wrist blood pressure devices per manufacturer instructions. |
| F0947 - Required In-Service Training for Nurse Aides: Failed to provide required dementia care in-service training for CNA staff. |
| F0884 - Reporting - National Health Safety Network: Failed to report complete COVID-19 information to CDC NHSN. |
| F0584 - Safe/Clean/Comfortable/Homelike Environment: Failed to maintain clean, comfortable, and homelike environment. |
| F0655 - Baseline Care Plan: Failed to complete baseline care plan within 48 hours of admission. |
| F0657 - Care Plan Timing and Revision: Failed to update resident care plans timely and accurately. |
| F0677 - ADL Care Provided for Dependent Residents: Failed to provide grooming and oral care for dependent residents. |
| F0695 - Respiratory/Tracheostomy Care and Suctioning: Failed to maintain oxygen equipment properly. |
| F0919 - Resident Call System: Failed to ensure call lights were functioning properly. |
| F0923 - Ventilation: Failed to maintain proper ventilation system to prevent odors. |
| F0925 - Maintains Effective Pest Control Program: Failed to maintain pest-free environment. |
| F0812 - Food Procurement,Store/Prepare/Serve-Sanitary: Failed to ensure proper food labeling, storage, and sanitary conditions in kitchen. |
| F0825 - Provide/Obtain Specialized Rehab Services: Failed to implement restorative nursing program for residents. |
| F0600 - Free from Abuse and Neglect: Failed to ensure residents free from verbal abuse and neglect. |
Report Facts
Inspections on page: 10
Total deficiencies: 82
Total surveys: 10
Licensing violations: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Administrator | Named in multiple findings related to staffing shortages, abuse investigations, and care plan reviews |
| Staff 2 | Director of Nursing (DNS) | Named in multiple findings related to staffing, infection control, abuse investigations, and care plan reviews |
| Staff 3 | Regional Nurse / Resident Care Manager | Named in findings related to infection control, medication administration, and care plan reviews |
| Staff 22 | Certified Nursing Assistant (CNA) | Named in infection prevention and control deficiencies related to PPE and hand hygiene |
| Staff 12 | Nursing Assistant (NA) | Named in verbal abuse incident and medication administration findings |
| Staff 14 | Dietary Manager | Named in findings related to dietary qualifications and food safety |
| Staff 7 | Registered Nurse (RN) | Named in medication administration errors and safe medication storage findings |
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