Nehalem Valley Care Center

In the surveyor’s words

From the most serious findings on record at Nehalem Valley Care Center, in the surveyor’s own words.

• Actual harm, isolatedF684Dec 22, 2021

  Based on interview and record review it was determined the facility failed to address residents' change of condition timely and provide medication as ordered for 4 of 6 sampled residents (#s 3, 6, 7 and 10) reviewed for a change in condition and pain medication. This placed residents at risk for a decline and increased pain and resulted in hospitalization for Resident 7. Findings include: 1. Resident 7 was admitted to the facility in 2015 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] -11/2/21 Resident 7 had jaundice and elevated liver enzymes. An ultrasound and abdominal CT scan were ordered and the resident declined to go the emergency department. -11/5/21 Resident 7 was seen for a follow up for jaundice. […]

• No harm, potential for more than minimal, widespreadF725Sep 4, 2026

  Based on observation, interview and record review it was determined the facility failed to ensure sufficient nursing staff were available to meet resident needs for 3 of 3 resident halls reviewed for staffing. This placed residents at risk for lack of timely assistance and unmet care needs. Findings include: On 9/3/26 the facility provided lists of residents who:-Required assistance with transfers: 10-Required a mechanical lift with transfers: 10- Required one or two-person assistance with bathing: 21-Required one or two-person assistance with toileting: 20-Required assistance with personal hygiene and dressing: 21These residents resided on all three facility halls. a. […]

• No harm, potential for more than minimal, widespreadF725Jun 26, 2025

  Based on interview and record review it was determined the facility failed to ensure sufficient nursing staff to meet resident care needs in a timely manner for 3 of 3 resident halls reviewed for staffing. This placed residents at risk for lack of timely assistance and unmet care needs. Findings include: Resident Council Notes indicated the following: -3/25/25: Showers were not being done. -4/30/25: CNAs were not getting residents to activities in a timely manner and meal service was late. […]

• No harm, potential for more than minimal, widespreadF727Jun 26, 2025

  Based on interview and record review it was determined the facility failed to ensure RN coverage for eight consecutive hours per day for 3 of 43 days reviewed for staffing. This placed residents at risk for unassessed needs and lack of care. Findings include: Review of the Direct Care Staff Daily Reports from 2/11/25 through 2/18/25 and 5/23/25 through 6/23/25 indicated there was no RN coverage for eight consecutive hours on 2/13/25, 2/15/25, and 6/20/25. On 6/26/22 at 10:17 PM Staff 1 (Administrator) and Staff 3 (Regional Nurse) acknowledged the facility lacked RN coverage on the identified days.

• No harm, potential for more than minimal, widespreadF812Feb 10, 2023

  Based on observation and interview it was determined the facility failed to ensure foods and bulk ingredients were labeled and stored in a way to minimize food spoilage, failed to maintain a clean and sanitary environment for storage of kitchen equipment and cookware and failed to wear hair restraints in 1 of 1 kitchen reviewed for sanitary conditions. This placed residents at risk for foodborne illness. Findings include: 1. On [DATE] at 10:53 AM the walk-in refrigerator in the facility's kitchen was observed to contain the following improperly stored items: -gallon carton of buttermilk (undated opened carton without a discard date); -ranch dressing (undated opened bottle without a discard date); -barbecue sauce (undated opened bottle without a discard date; food debris was observed on… […]