Corvallis Manor Nursing & Rehabilitation Center

Inspectors wroteBased on interview and record review it was determined the facility failed to develop an assessment of the facility's water systems and conduct a risk analysis assessment for potential areas of growth and spread of water-borne pathogens and illness. This placed all residents at risk for exposure to water-borne pathogens.

Inspectors wroteBased on interview, observation, and record review it was determined the facility failed to ensure medications were safely stored with proper temperature monitoring for 1 of 2 refrigerators reviewed for medication storage. This placed all residents with refrigerated medications at risk for receiving ineffective or unstable medications, including insulin.

Inspectors wroteBased on interview and record review it was determined the facility failed to provide residents with written bed hold notifications, including reserved bed hold payments, at the time of transfer to the hospital and failed to provide appropriate information to a provider for 2 of 4 sampled residents (#s 4 and 96) reviewed for hospitalization and discharge. This placed residents at risk for rehospitalization and a lack of knowledge regarding their choices and potential financial responsibilities.

Inspectors wroteBased on interview and record review it was determined the facility failed to implement a baseline care plan for required care and interventions for 1 of 4 sampled residents (#105) reviewed for ADLs. This placed residents at risk for unmet needs and unnecessary pain.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to develop and implement a comprehensive care plan for 2 of 4 sampled residents (#s 82 and 84) reviewed for ADLs. This placed residents at risk for unmet care needs related to toileting hygiene and meal tray set up for dependent residents.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a dependent resident received assistance with toileting hygiene for 1 of 1 sampled resident (#82) reviewed for bowel incontinence. This placed residents at risk for skin related issues and infections.

Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician orders and to document or provide necessary wound care for 2 of 6 sampled residents (#s 4 and 95) reviewed for UTIs, wound care and medications. This placed residents at risk for untreated weight gain, infections and worsening wounds.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a nurse assessed residents in a timely manner after returning from dialysis for 1 of 1 sampled resident (#6) reviewed for dialysis. This placed residents at risk for delayed treatment and dialysis complications.

Inspectors wroteBased on interview and record review, it was determined the facility failed to ensure adequate monitoring and indications for use of blood pressure medication for 1 of 5 sampled residents (#84) reviewed for unnecessary medications. This placed residents at risk for receiving blood pressure medications without adequate monitoring and indications for use.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide cut up foods for 1 of 4 sampled residents (# 84) reviewed for food. This placed residents at risk for unmet individualized food needs.

Inspectors wroteBased on interview and record review, it was determined the facility failed to investigate an unwitnessed fall and misappropriation of property for 2 of 13 sampled residents (#s 11 and 14) reviewed for falls and misappropriation. This placed residents at risk for stolen property and neglect.

Inspectors wroteBased on interview and record review it was determined the facility failed to provide pain medications as ordered for 1 of 3 sampled residents (#1) reviewed for medications. This placed residents at risk for unmanaged pain.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure sufficient nursing staff were available to meet the needs of residents in a timely manner for 2 of 3 sampled residents (#s 11 and 12) reviewed for staffing. This placed residents at risk for delayed care.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure a dependent resident received ADL assistance for 1 of 3 sampled residents (#1) reviewed for accidents. This placed residents at risk for unmet needs and dignity.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure physician orders for eye treatments were followed for 1 of 3 sampled residents (#4) reviewed for physician orders. This placed residents at risk for eye pain and complications.

Inspectors wroteBased on interview and record review it was determined the facility failed to follow a resident's care plan to prevent falls for 1 of 3 sampled residents (#1) reviewed for accidents. This placed residents at risk for injuries from falls.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to check the Hoyer (a mechanical lift device used to transfer residents) straps to prevent a fall and failed to follow care plan interventions to prevent injury for 2 of 5 (#s 10 and 11) sampled residents. As a result, Resident 11 sustained a subarachnoid hemorrhage, (bleeding in the space between the brain and the tissue covering the brain), an intraparenchymal hemorrhage (bleeding within the brain's functional tissue) a scalp hematoma (blood clot), multilevel acute compression fractures (the back bones collapse due to a forceful impact) involving the thoracic region (middle of the back) and a compression fracture of L4 vertebra (lumbar region, lower back).

Inspectors wroteBased on interview and record review it was determined the facility failed to report injuries of unknown origin for 1 of 5 sampled residents (#10) reviewed for abuse reporting. This placed residents at risk for abuse and neglect.

Inspectors wrote2. Resident 14 was admitted to the facility in 2/2025 with a diagnosis of diabetes. Per epocrates (online pharmacy resource) revealed insulin aspart (hormone to decrease blood sugars) was a fast acting insulin that started to work in about 15 minutes after injection, peaked in about one hour, and kept working for two to four hours. Instructions included you should eat a meal within 5 to 10 minutes. A 2/17/25 admission MDS revealed Resident 14 was cognitively intact. A 3/2025 Diabetic Administration Record (DAR) revealed on 3/13/25 Resident 14 received aspart at 12:00 PM. On 3/13/25 at 1:43 PM Resident 14 stated she/he just ate lunch at 1:20 PM. Resident 14 stated she/he did not have any symptoms of low blood sugars. [...]

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure food temperatures were maintained for meals served from 1 of 1 facility kitchen and 2 of 4 sampled residents (#s 56 and 61) reviewed for food. This placed residents at risk for food that was not palatable, safe, or appetizing.

Inspectors wroteBased on observation, interview and record review the facility failed to assess a resident for safe self-administration of medication for 1 of 1 sampled resident (#50) reviewed for anticoagulant medications. This placed resident at risk for adverse side affects.

Inspectors wroteBased on interview and record review it was determined the facility failed to provide a clean environment as well as functioning phones and lights for 2 of 6 sampled residents (#s 33 and 174) reviewed for environment. This placed residents at risk for an unclean, unsafe, and unhomelike environment.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure grievances were acted upon timely for 1 of 5 sampled residents (#14) reviewed for dignity and missing property. This placed residents at risk for unresolved needs.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to incorporate PASARR (Preadmission Screening and Resident Review) Level II recommendations for 1 of 1 sampled resident (# 50) reviewed for PASARR coordination of care. This placed residents who have a mental health disorder at risk for delayed care and services to attain their highest practicable level of well-being.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 2 of 4 sampled residents (#s 61 and 124) reviewed for ADLs. This placed residents at risk for lack of personal hygiene and skin injuries.

Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician orders for treatment of a resident's pressure ulcer for 1 of 5 sampled residents (#20) reviewed for medications. This placed residents at risk for worsening pressure ulcers.

Inspectors wroteBased on interview, and record review it was determined the facility failed to provide appropriate foot care for 1 of 2 sampled residents (#s 22) reviewed for skin. This placed residents at risk for infections.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure resident water temperatures were safe for 3 of 6 sampled residents (#s 2, 10, and 17) and 1 of 1 therapy gym reviewed for water temperatures. This placed residents at risk for burns.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to assess a resident's ability to self-catheterize (sterile tube inserted into the bladder through the urethra [tube that goes from the bladder to the outside of the body] to drain the urine) for 1 of 1 sampled resident (#25) reviewed for UTI. This placed residents at risk for recurrent UTIs.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure accurate communication occurred between the facility and the dialysis provider and daily weight were obtained per physician orders for 1 of 1 sample resident's (#224) reviewed for dialysis. This placed residents at risk for potential complications and dialysis care and treatment.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure a resident who was a history of trauma received trauma-informed care for 1 of 1 sampled resident (#22) reviewed for mood and behavior These placed residents at risk for unmet trauma needs and a decrease in their quality of life.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure a resident's use of bed rails was assessed for 1 of 1 sampled resident (#124) reviewed for side rails.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure recommended mental health services were provided for 1 of 5 sampled residents (#18) reviewed for unnecessary medications. This placed residents at risk for unmet needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to provide timely pharmaceutical services for 1 of 1 sampled resident (#174) reviewed for insulin. This placed residents at risk for elevated blood sugars.

Inspectors wroteBased on interview and record review it was determined the facility failed to provide appropriate monitoring and dosing of medications for 3 of 5 sampled residents (#s 10, 18, and 20) reviewed for medications. This placed residents at risk for an adverse medication regimen.

Inspectors wroteBased on interview and record review it was determined the facility failed to complete a GDR (gradual dose reduction) and appropriately monitor a resident on psychotropic medications for 2 of 5 sampled residents (#s 10 and 20) reviewed for medications. This placed residents at risk for adverse medication regimen.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to promptly notify the ordering physician of laboratory results for 1 of 1 sampled residents (#37) reviewed for antibiotics. This placed residents at risk for unmet needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure lab results were in the resident record for 1 of 5 sampled residents (#10) reviewed for medications. This placed residents at risk for incomplete records.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to make reasonable efforts to deliver a menu based on resident requests and preferences for 2 of 2 residents (#s 7 and 61) during random observations. This placed residents at risk for unmet food preferences.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to follow infection control standards for contact and Enhanced Barrier Precautions for 3 of 7 sampled residents (#s 7, 20, and 274) reviewed for infection control. This placed residents at risk for exposure and contraction of infectious diseases.

Inspectors wroteBased on interview and record review it was determined the facility failed to provide antibiotic stewardship for 1 of 1 sampled resident (#25) reviewed for UTIs. This placed residents at risk for drug resistant organisms.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to maintain essential kitchen equipment for 1 of 1 kitchen reviewed for kitchen services. This placed residents at risk for food borne illnesses.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide modified textured diets as ordered for 2 of 3 sampled residents (#s 1 and 2 ) reviewed for food. This placed residents at risk for medical complications and aspiration.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure sufficient nursing staff to maintain the highest practicable physical and psychosocial well-being for 3 of 3 Resident Halls reviewed for staffing. This placed residents at risk for unmet care needs and psychosocial harm.

Inspectors wroteBased on observation, interview and record review it was determined meals were not served at the proper temperature for 1 of 1 kitchens reviewed for meal service. This placed residents at risk for food not being served at the appropriate temperature.

Inspectors wroteBased on observation and interview it was determined the facility failed to provide maintenance services to maintain a safe, comfortable and homelike environment for 2 of 3 resident rooms (Room #s 117 and 118) reviewed for environment. This placed residents at risk of outside air and odors entering the resident rooms.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure the resident's right to be free from neglect for 1 of 3 sampled residents (#1) reviewed for abuse. This placed residents at risk for unmet care needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to staff a RN for eight consecutive hours per day seven days per week for 22 out of 91 days reviewed for staffing. This placed residents at risk for unmet assessment needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to obtain consent and review risks and benefits prior to administering a COVID-19 vaccination to 1 of 3 sampled residents (#9) reviewed for immunizations. This placed residents at risk for adverse side effects from the vaccine.

Inspectors wroteBased on interview and record review it was determined Staff 5 (Agency RN) failed to follow standards of practice related to insulin administration and failed to be honest during an investigation for 1 of 3 sampled residents (#2) reviewed for medications. This placed residents at ongoing risk of jeopardized health status and blood borne pathogens.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident was free from a significant medication error for 1 of 3 sampled residents (#2) reviewed for medications. This placed residents at risk of jeopardized health status and blood borne pathogens.

Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician orders for 4 of 10 sampled residents (#s 20, 23, 63, and 66) reviewed for medications, hospitalization, and pressure ulcers. Resident 63 required acute care intervention for fluid overload.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to accurately assess, care plan, and provide pressure ulcer treatments for 2 of 3 sampled residents (#s 17 and 66) reviewed for pressure ulcers. Resident 17 experienced multiple worsening pressure ulcers.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to maintain acceptable parameters of nutritional status for 2 of 5 sampled residents (#s 52 and 375) reviewed for nutrition. Resident 52 experienced a severe weight loss of over 13 percent in less than three months.

Inspectors wroteBased on interview and record review it was determined the facility failed to provide a response for Resident Council concerns for 1 of 1 Resident Council reviewed for grievances. This placed residents at risk for a decline in psychosocial well-being.

Inspectors wroteBased on interview and record review it was determined the facility failed to assist or follow up with residents related to their desire to formulate an advance directive for 4 of 4 sampled residents (#s 14, 20, 41 and 56) reviewed for advance directives. This placed residents at risk for not having their healthcare decisions honored.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 5 of 13 sampled residents (#s 4, 6, 21, 52, and 225) reviewed for accidents and ADLs. This placed residents at risk for unmet needs.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide sufficient staffing to meet the needs of 1 of 8 sampled residents (#36) and 1 of 1 facility reviewed for staffing. This placed residents at risk for unmet needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 5 of 5 sampled CNA staff (#s 8, 21, 22, 23, and 24) reviewed for staffing. This placed residents at risk for a lack of competent staff.

Inspectors wroteBased on interview and record review it was determined the facility failed to address pharmacy recommendations for 3 of 5 sampled residents (#s 41, 46, and 54) reviewed for medications. This placed residents at risk for adverse medication reactions.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure residents did not receive unnecessary medications for 6 of 6 sampled residents (#s 20, 23, 42, 46, 54, and 62) reviewed for hospice and medications. This placed residents at risk for adverse side effects of medications.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure proper flavor and appealing food textures for 1 of 1 kitchen and 1 of 13 sampled residents (#8) observed during dining observations. This placed residents at risk for meal dissatisfaction.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure resident records were accurate for 3 of 17 sampled residents (#s 8, 14, and 66) reviewed for ADLs, dialysis, nutrition and PU. This placed residents at risk for inaccurate and incomplete clinical records.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to follow infection control standards for 1 of 1 facility reviewed for infection control. This placed residents at risk for exposure and contraction of infectious diseases.

Inspectors wroteBased on interview, and record review it was determined the facility failed to have a system in place to track annual nurse aide training for the required 12 hours of in-service training annually for 5 of 5 sampled CNAs (#s 8, 21, 22, 23, and 24) reviewed for sufficient and competent nurse staffing. This placed residents at risk for lack of competent staff.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide a comfortable shower chair for 1 of 9 sampled residents (#14) reviewed for ADLs. This placed residents at risk for unmet bathing needs.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide a homelike environment for 1 of 1 facility reviewed for environment. This placed residents at risk for an unpleasant environment.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident grievance was resolved timely for 1 of 3 sampled residents (#375) reviewed for nutrition. This placed residents at risk for unresolved concerns.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident or resident representative was provided a bed hold policy for 1 of 1 sampled resident (#63) reviewed for hospitalization. This placed residents at risk for lack of knowledge related to the right to return to the facility.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to develop a baseline care plan to address residents' immediate care needs for 3 of 9 sampled residents (#s 4, 21, and 225) reviewed for ADLs. This placed residents at risk for unmet care needs.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to develop care plans for 2 of 7 sampled residents (#s 6 and 375) reviewed for pain and accidents. This placed residents at increased risk for unmet needs.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure care plans were updated for 2 of 2 sampled residents (#s 8 and 11) reviewed for dialysis (process to purify blood) and care plans. This placed residents at risk for lack of appropriate care.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to obtain eye care services for 1 of 1 sampled resident (#8) reviewed for vision. This placed residents at risk for lack of appropriate eye care services and devices.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure a resident's environment remained free from accident hazards for 1 of 4 sampled residents (#20) reviewed for accidents. This placed residents at risk for accidents.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure resident's respiratory equipment was maintained for 2 of 3 sampled residents (#s 21 and 225) reviewed for respiratory needs. This placed residents at risk for respiratory complications.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident was offered pain medication when assessed to have pain for 1 of 3 sampled residents (#375) reviewed for pain. This placed residents at risk for unaddressed pain.

Inspectors wroteBased on interview and record review it was determined the facility failed to comprehensively assess dementia needs for 1 of 2 sampled residents (#23) reviewed for dementia. This placed residents at risk for unmet needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident's physician was notified of abnormal laboratory results for 1 of 5 sampled residents (#375) reviewed for nutrition. This placed residents at risk for delayed care.

Inspectors wroteBased on interview, and record review it was determined the facility failed to have an effective new staff orientation program for 2 of 3 staff members (#s 12 and 13) reviewed for staffing and orientation. This placed residents at risk for untrained staff.

Inspectors wroteBased on interview and record review it was determined the facility failed to provide care and services in compliance with professional standards for 2 of 2 staff (#s 4 and 5) reviewed for medication errors. This failure was determined to be an immediate jeopardy situation because Staff 4 (Agency RN) and Staff 5 (LPN) both administered 100 mg of oxycodone (narcotic pain medication) rather than the prescribed 5 mg within a four-hour period.

Inspectors wroteBased on Based on interview and record review it was determined the facility failed to ensure narcotic pain medication was administered as ordered for 1 of 2 sampled residents (#1) reviewed for medication errors. This failure was determined to be an immediate jeopardy situation because Resident 1 received 100 mg of oxycodone (narcotic pain medication) rather than 5 mg as ordered twice within a four-hour period.

Inspectors wroteBased on interview and record review it was determined the facility failed to recognize and respond to Resident 2's respiratory status change of condition for 1 of 3 sampled residents (#2) reviewed for change in condition. This failure was determined to be an immediate jeopardy situation because the facility failed to recognize, treat, and notify the provider of Resident 2's respiratory decline which resulted in hospitalization for pneumonia and death.