Oregon Care Center

Inspectors wroteBased on interview and record review, the facility failed to inform residents and/or their responsible parties, in advance of the risks and benefits of proposed care. When the facility failed to obtain written consent before beginning psychotropic medications (medications that affect the mind, emotions, and behavior) for two Residents (Resident #5, and Resident #7) of the 12 sampled residents. The facility census was 46. Review of the facilities Use of Psychotropic Medications policy, dated 5/9/25, showed: Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication in advance of such initiation or increase. 1. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the resident's right to personal privacy and confidentiality of his or her personal and medical records when CMT (Certified Medication Technician) A walked away from the computer on the medication cart leaving confidential resident information open on the computer screen. This affected three (Resident #7, #16, and #32) of 12 sampled residents. The facility census was 46. Review of the Nursing Home Resident Right's policy, undated, showed: -Resident's have a right to privacy regarding personal, financial, and medical affairs;-Resident's have a right to privacy during treatment and care of personal needs. 1. [...]

Inspectors wroteBased on observation and interview the facility failed to provide a safe, comfortable and homelike environment. This affected all residents. The facility census was 46. Review of the facility's Safe and Homelike Environment Policy, dated 6/15/25 showed:-The facility will provide a safe, clean, comfortable and homelike environment;-Environment refers to any place in the facility that is frequented by residents, including dining areas and hallways. Review of the facility's Resident Environmental Quality Policy, dated 6/15/25 showed:-The facility shall be equipped and maintained to provide a safe, functional, and comfortable environment for the residents;-The facility will provide maintenance of the building to maintain a safe and homelike environment. [...]

Inspectors wroteBased on interview and record review the facility failed to maintain the resident's highest practicable level of physical, mental and psychosocial well-being that prevents or minimizes adverse consequences related to medication therapy to the extent possible, by providing oversight by a licensed pharmacist for three residents (Resident #5, #24, and #19) of the 12 sampled residents, when the facility to complete and follow the recommendations for a medication review. The facility census was 46. The facility did not provide the requested policy regarding Drug Regimen Reviews. Review of the facility's Gradual Dose Reduction of Psychotropic Drugs policy dated 6/6/25 showed that residents who use psychotropic drugs will receive gradual dose reductions unless clinically contraindicated. 1. [...]

Inspectors wroteBased on observation and interview the facility failed to prepare and serve food in accordance with professional standards of food service when the facility failed ensure the kitchen and dining room were in good repair. The facility census was 46. The facility did not provide the requested policy on repairs of the kitchen and dining room. 1. Observation on 12/02/25 at 12:23 P.M., showed:-A black substance on the wall behind sink in the dish area;-Five broken tiles and two missing tiles under the dishwasher;-The exit door leading into the dining room by the steam table with black stains along the edges and a black area around the door knob; [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a reassessment of the Level I preadmission screening resident review (PASARR) assessment (used to identify individuals with mental illness or intellectual/developmental disabilities completed before admission to the nursing facility and when a resident had a new diagnosis of a mental illness) for one (Resident #5) of the 12 sampled residents, when the resident had a new diagnosis of a serious mental illness. The facility census was 46. Review of the facilities Resident Assessment- Coordination with PASARR Program policy, dated 6/30/25, showed: Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. [...]

Inspectors wroteBased on observation and interview, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls when the facility failed to ensure that three bottles of lorazepam, a schedule IV medication (a controlled medication used to treat mood and behavior), was secured behind two locks. The facility census was 46. Review of the facilities Medication Storage policy, dated 5/9/25, showed: Schedule II drugs and back-up stock of schedule III, IV, and V medications are stored under double-lock and key. Observation of the medication room on 12/02/2025 at 4:17 P.M. showed:- Medication refrigerator that contained three bottles of liquid lorazepam was not locked;-The lock for the medication fridge was sitting on a counter in the medication room;- A piece of the locking mechanism on the fridge in the medication room was not attached to the fridge. [...]

Inspectors wroteBased on interviews and record review, the facility failed to protect the resident's right to be free from physical abuse when Resident #1 entered Resident #2's room and kicked Resident #2 in the shin resulting in pain and redness for Resident #1. The deficient practice affect one of four sampled residents. The facility census was 41. On 1/28/25, the Administrator was notified of the past noncompliance situation which occurred on 1/28/25. On 1/28/25, facility administration was notified of the incident, an investigation immediately began and corrective actions were implemented. The noncompliance was corrected on 1/30/25. Review of the facility's policy titled, Abuse and Neglect, revised 9/24, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to employ a qualified director of food and nutrition services. This deficient practice had the potential to affect 44 of 44 residents who received meals prepared in the facility's only kitchen. The facility census was 44.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to protect a resident's right to be free of physical abuse for one of two residents (Resident (R)16) reviewed for abuse out of a total sample of 15. This failure increased the risk of abuse towards residents. The facility census was 44. As a result of an Informal Dispute Resolution on 12/31/24, the deficiency was changed to past noncompliance, which began on 11/17/24. Upon discovery, the facility administration immediately conducted an investigation and corrective actions were implemented. The deficiency was corrected on 11/17/24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1.) ensure staff was knowledgeable of the proper usage of insulin pens for one of one resident (Resident (R) 20) who received insulin through an insulin pen. This failure had the potential to cause R20 to receive an incorrect dose of insulin, and 2.) failed to ensure physician orders recorded the volume of tube feeding formula to be provided for one of one resident (R41) reviewed for tube feedings out of a total sample of 15. This failure had the potential to cause unexpected weight changes and/or R41's nutritional needs to be unmet. The facility census was 44.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store medications in a locked storage area to ensure medications were inaccessible to unauthorized staff and residents, and when the medications were left in pill cups on the dining table for residents in the dining room (Resident #1 and #2) and when the facility failed to lock a medication cart. The facility census was 46. Review of facility policy, dated December 2016, showed: -Residents have right to self-administer medications if the interdisciplinary team had determined that it was clinically appropriate and safe for resident to do so. -If nursing team determined that a resident cannot safely self-administer medications, the nursing staff will administer the resident's medications. Review of facility policy, storage of medications, undated, showed: [...]

Inspectors wroteBased on observation, record review, and interview the facility failed to prepare and serve food in accordance with professional standards for food service safely when staff failed to maintain daily readings of refrigerator and freezer temperature logs, failed to follow proper hand washing practices, used hand sanitizer in food preparation, failed to change gloves between tasks, did not store plates and bowls inverted, did not sanitize thermometer dropped on floor, did not apply hair nets prior to entering kitchen, did not date and label spices, did not throw out expired spices, did not run food processor through dishwasher between uses, and did not maintain a clean and sanitary kitchen. The facility census was 46. 1. Review of facility policy, Food Safety and Sanitation, undated, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week. The facility census was 47. The facility did not provide a policy regarding RN staffing. Review of facility staffing for May 2024 showed : -No RN scheduled for 5/18/2024 for eight consecutive hours. Review of facility staffing for June 2024 showed: -No RN scheduled for 6/1/24, 6/8/24, 6/24/24 for eight consecutive hours. Review of the facility staffing for July 2024 showed: -No RN scheduled for 7/4/24, 7/20/24, 7/26/24 for eight consecutive hours. During an interview on 8/2/24 at 2:22 P.M., the Administrator said: -He/She was aware there are days that the facility does not have RN coverage. -It is her expectation that the facility does have required and appropriate RN coverage.

Inspectors wroteBased on interview and record review, the facility failed to provide personal funds and a final accounting within thirty days upon discharge. This affected fourteen additionally sampled residents, (Resident #147, #148, #149, #150, #151, #152, #153, #154, #155, #156, #157, #158, and #159.) Facility census was 42. 1. Review of facility Refund Policy, undated, showed; -When a resident is discharged or expired, refunds to families or payments received shall be withheld for a period of 30 days. This policy was adopted due to the billing procedures of the companies that work with [NAME] Care Centers, INC. -All refunds will be based on the daily rate less supplies and charges used by the resident. Day of admission and not the day of discharge will be charged. Review of the facility policy Personal Fund Account, undated, showed; [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure they maintained a Department of Health and Senior Services (DHSS) approved surety bond in an amount to cover any loss of theft to residents' money held in the facility's Resident Trust Fund (RTF) account which affected all residents who had money held in their RTF account. The facility census was 42. Review of facility policy titled Policy for Surety Bond, undated, showed: -The Oregon Care Center will maintain Surety bond in accordance with State and Federal Regulations. The purpose of the surety bond is to guarantee that the facility will pay the resident (or the State on behalf of the resident) for losses occurring from any failure by the facility to hold, safeguard, manage, and account for the residents funds, i.e., losses occurring as a result of acts or errors of negligence, incompetence, or dishonesty. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure quarterly assessments were completed within 92 days following the previous assessment for two residents (Residents #1 and #4). Facility census was 42. Facility Policy Resident Assessment Instrument (RAI) Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff: -Quarterly Assessments must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual changes in a resident's status are monitored. -Facilities may institute various processes to create the assessment schedules, however it is the responsibility of the MDS coordinator to ensure scheduling accuracy and timeliness. Late Assessments are considered unacceptable practice. 1. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to maintain accurate assessments to reflect resident statuses when antipsychotics were inaccurately coded for one resident (Resident #42), anticoagulants were not coded for one resident (Resident #12), ventilator and urinary tract infection (UTI) were inaccurately coded for one resident (Resident #12), and restraints were inaccurately coded for one resident (Resident #17). Facility census was 42. Review of facility policy, Resident Assessment Instrument (RAI) Minimum Data Set (MDS) a federally mandated assessment instrument completed by staff, dated April 2022, showed: -Quarterly Assessments must be completed at least every 92 days following the previous OBRA assessment of any type. [...]

Inspectors wroteBased on observation and interviews, the facility failed to maintain medication storage when loose pills were found in the medication cart and expired medications found in the medication room. Facility census was 42. Review of facility policy, Policy for Medication Administration and Maintenance, not dated, did not address loose pills or expired medications. Observation and interview on 09/21/22 at 11:16 A.M. of the North Hall Cart showed and Certified Medication Technician (CMT) A said: -Three loose white pills in drawers. -He/she destroyed the loose pills. -He/she said the cart is checked every day. Observation and interview on 09/22/22 at 08:18 A.M. of the Medication Room showed and Licensed Practical Nurse (LPN) A said: -The medication room is checked monthly for outdates. -Two bottles of over the counter Vitamin D3 10 micrograms (mcg) unopened; expired 07/22. [...]