Inspection Reports for South Hills Rehabilitation Center
1166 E. 28th Avenue, OR, 97403
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Inspection Report
Capacity: 110
Deficiencies: 43
Dec 9, 2025
Visit Reason
State-compiled facility profile showing 10 inspections from 2024-2025 with detailed deficiency history and enforcement notices
Findings
Across multiple inspections from 2024 to 2025, the facility exhibited numerous deficiencies including failures in resident care, staffing shortages, infection control lapses, abuse prevention, and administrative compliance. Several deficiencies were corrected while others remained uncorrected at the time of the latest inspections.
Complaint Details
Multiple inspections included complaint investigations related to abuse, neglect, staffing, and care concerns. Specific complaints involved verbal abuse of residents, failure to report and investigate abuse timely, and inadequate staffing leading to unmet resident needs.
Deficiencies (43)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| F0684 - Quality of Care: Failure to ensure proper medication administration and clinical assessments |
| F0695 - Respiratory/Tracheostomy Care and Suctioning: Failure to follow physician orders for oxygen administration |
| M0000 - Initial Comments |
| M9999 - STATE OF OREGON ADMINISTRATIVE RULES |
| F0554 - Resident Self-Admin Meds-Clinically Approp: Failure to assess residents for self-administration of medications |
| F0580 - Notify of Changes (Injury/Decline/Room, etc.): Failure to notify physician of resident's change of condition |
| F0600 - Free from Abuse and Neglect: Failure to protect residents from verbal abuse and failure to intervene |
| F0609 - Reporting of Alleged Violations: Failure to timely report abuse and investigations |
| F0610 - Investigate/Prevent/Correct Alleged Violation: Failure to conduct timely and thorough investigations |
| F0628 - Discharge Process: Failure to provide bed hold notices and discharge information |
| F0725 - Sufficient Nursing Staff: Failure to maintain adequate nursing and CNA staffing levels |
| F0812 - Food Procurement,Store/Prepare/Serve-Sanitary: Failure to follow proper hand hygiene in food preparation |
| F0814 - Dispose Garbage and Refuse Properly: Failure to maintain dumpster lid closed and proper refuse disposal |
| F0880 - Infection Prevention & Control: Failure to follow infection control standards including hand hygiene and equipment disinfection |
| M0185 - Bariatric Criteria and Services: Failure to maintain minimum CNA staffing for bariatric residents |
| F0561 - Self-Determination: Failure to provide meal choices and communication |
| F0565 - Resident/Family Group and Response: Failure to respond timely to resident concerns |
| F0576 - Right to Forms of Communication w/ Privacy: Failure to deliver mail on Saturdays |
| F0577 - Right to Survey Results/Advocate Agency Info: Failure to make past survey results readily available |
| F0584 - Safe/Clean/Comfortable/Homelike Environment: Failure to maintain rooms in good repair |
| F0585 - Grievances: Failure to address resident's missing items timely |
| F0604 - Right to be Free from Physical Restraints: Failure to monitor physical restraint use |
| F0628 - Discharge Process: Failure to provide discharge notices and bed hold policy |
| F0637 - Comprehensive Assessment After Significant Change: Failure to complete timely Significant Change MDS |
| F0657 - Care Plan Timing and Revision: Failure to revise care plans to reflect current resident needs |
| F0677 - ADL Care Provided for Dependent Residents: Failure to provide required assistance with ADLs |
| F0688 - Increase/Prevent Decrease in ROM/Mobility: Failure to provide splints as ordered |
| F0689 - Free of Accident Hazards/Supervision/Devices: Failure to provide adequate supervision and accident prevention |
| F0690 - Bowel/Bladder Incontinence, Catheter, UTI: Failure to provide catheter care and follow-up |
| F0692 - Nutrition/Hydration Status Maintenance: Failure to maintain nutritional status |
| F0697 - Pain Management: Failure to manage resident pain effectively |
| F0727 - RN 8 Hrs/7 days/Wk, Full Time DON: Failure to staff RN for required hours |
| F0730 - Nurse Aide Perform Review-12 hr/yr In-Service: Failure to complete annual CNA performance reviews |
| F0756 - Drug Regimen Review, Report Irregular, Act On: Failure to act on pharmacy recommendations |
| F0757 - Drug Regimen is Free from Unnecessary Drugs: Failure to obtain routine labs to monitor medications |
| F0776 - Radiology/Other Diagnostic Services: Failure to reschedule colonoscopy |
| F0791 - Routine/Emergency Dental Srvcs in NFs: Failure to obtain dental services |
| F0809 - Frequency of Meals/Snacks at Bedtime: Failure to provide requested snacks |
| F0849 - Hospice Services: Failure to coordinate care with hospice |
| F0851 - Payroll Based Journal: Failure to submit mandatory staffing data |
| F0881 - Antibiotic Stewardship Program: Failure to ensure antibiotic indication and monitoring |
| F0880 - Infection Prevention & Control: Failure to follow infection control standards |
Report Facts
Inspections on page: 10
Total deficiencies: 61
Total surveys: 10
Licensing violations: 20
Notices: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Administrator | Named in multiple findings related to investigations, abuse reporting, and administrative oversight |
| Staff 2 | Director of Nursing Services (DNS) | Named in multiple findings related to investigations, abuse reporting, staffing, and care oversight |
| Staff 4 | CNA | Named in verbal abuse findings and infection control breach |
| Staff 6 | Regional Nurse | Named in oxygen administration and infection control findings |
| Staff 26 | Staff Development Coordinator RN | Named in multiple findings related to investigations, abuse reporting, and medication monitoring |
| Staff 27 | Director of Therapy Services | Named in pain management findings |
| Staff 28 | LPN Unit Manager | Named in abuse and notification findings |
| Staff 30 | Dietary Aide | Named in hand hygiene deficiency |
| Staff 31 | Dietary Manager | Named in food service and garbage disposal deficiencies |
| Staff 32 | CNA | Named in infection control findings |
| Staff 36 | Speech Therapist | Named in abuse reporting findings |
| Staff 37 | Regional Nurse Consultant | Named in multiple investigation and administrative findings |
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