Keizer Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Keizer Nursing and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF692Feb 28, 2023

  Based on observation, interview and record review it was determined the facility failed to ensure residents maintained acceptable parameters of nutritional status for 2 of 2 sampled residents (#s 18 and 19) reviewed for nutrition. As a result Resident 19 had a severe weight loss of 10.50% in 38 days. This placed residents at risk for further weight loss. Findings include: 1. Resident 19 readmitted to the facility in 2022 with diagnoses including failure to thrive, stroke and dementia. The 1/9/23 Care Plan indicated Resident 19 had a nutritional problem and had right sided hemiparesis (paralysis to one side of the body). The RD was to evaluate and make diet change recommendations PRN. The 2/1/23 physician order indicated Resident 19 was to receive a house supplement 118 ml. one time daily. […]

• No harm, potential for more than minimal, widespreadF812Dec 17, 2025

  Based on observation and interview the facility failed to ensure resident meals were prepared in a sanitary manner for 1 or 1 kitchens reviewed for sanitation. This placed residents at risk for foodborne illnesses. Findings include:On 12/16/25 at 10:01 AM, Staff 7 (Cook) stated the residents were given meal tickets to complete each day and those tickets were tallied and utilized by the facility during meal planning and plating. During observations on 12/16/25 at 12:10 PM, Staff 7 picked up resident tickets with gloved hands, then picked up bread rolls and placed them on lunch plates with the same gloved hands. This pattern repeated throughout the meal service. […]

• No harm, potential for more than minimal, widespreadF732Feb 27, 2024

  Based on observation, interview and record review the facility failed to ensure the Direct Care Staff Daily Report (DCSDR) form was in a prominent place, readily accessible to residents and visitors for 1 of 1 facility reviewed for staffing. This placed residents and visitors at risk for lack of awareness of nurse staffing levels. Findings include: Random observations from 2/13/24 through 2/16/24 and 2/26/24 through 2/27/24 revealed the DCSDR form was attached to a clipboard and placed inside an opaque file folder. The opaque file folder was mounted to the wall across from the nurses station. The DCSDR was not easily identifiable, and as a result, residents and visitors were unable to view the census or the number of staff working during each shift. […]

• No harm, potential for more than minimal, widespreadF812Feb 3, 2022

  Based on observation, interview, and record review it was determined the facility failed to prepare, distribute, and serve food in accordance with professional standards of food service and ensure the kitchen equipment was clean and properly maintained for 1 of 1 kitchen reviewed. This placed residents at risk for cross-contamination and foodborne illness. Findings include: 1. On 1/20/22 at 9:52 AM through 10:14 AM continuous observations were made during the initial kitchen tour and the following was observed: *Food residue in the handwashing sink. Staff 6 (Cook) confirmed he used the sink to dump Cream of Wheat from breakfast and at times used the sink for food preparation and disposal. […]

• No harm, potential for more than minimal, widespreadF842Feb 3, 2022

  Based on observation and interview it was determined the facility failed to ensure access to complete resident medical records for 1 of 1 facility reviewed. This placed residents at risk for unmet care needs. Findings include: On 2/2/22 at 12:24 PM Staff 10 (LPN) was observed to be on a computer to access the electronic health record. Staff 10 stated she did not have access to resident medical records prior to 10/22/21. On 2/2/22 at 10:55 AM Staff 3 (Regional RN) stated the new company took over the building on 11/1/21 and staff were unable to access records beyond the previous 90 days from the look back date. Staff 3 further stated administration staff could get access to historical data but other staff did not have access to those historical medical records.