Oregon Care Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF801Nov 21, 2024

  Based 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. Findings include: Review of the list of the facility's Key Personnel provided by the facility revealed [Name of the Dietary Manager (DM)] as Dietary Manager. Review of the DM's Food Services Director Job Description, dated 07/01/23, revealed the education required for the position was, Certification as Dietary Manager- Association of Nutrition and Foodservice Professionals (ANFP). […]

• No harm, potential for more than minimal, patternF552Dec 4, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF583Dec 4, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF584Dec 4, 2025

  Based 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.Review of the facility's Handrails Policy,… […]

• No harm, potential for more than minimal, patternF756Dec 4, 2025

  Based 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. […]