Oregon Living and Rehabilitation Center

In the surveyor’s words

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

• Actual harm, isolatedF805Aug 17, 2023

  Based on observation, interview, and record review the facility failed to ensure mechanically altered diets were the appropriate consistency. This failure resulted in R10 requiring emergency care after choking on pizza. This applies to 1of 19 (R10) residents reviewed for mechanically altered diets in the sample of 19. The findings include: The facility face sheet for R10 shows diagnosis to include chronic obstructive pulmonary disease, dysphagia and history of cerebral infarction. The facility assessment dated [DATE] shows R10 to be cognitively intact and requires limited assistance with eating. […]

• No harm, potential for more than minimal, widespreadF755Apr 2, 2026

  The facility failed to ensure accurate reconciliation and disposition of controlled substances. The facility also failed to have adequate policies for the reconciliation and disposition of controlled substances. These failures resulted in the facility being unable to account for a resident's controlled substances. This failure has the potential to affect all residents residing in the facility. The findings include:The facility provided census for 4/2/26 showed 65 residents resided at the facility. The facility's North Unit Controlled Substance Accountability Record Card-Sheet Count (commonly referred to as a card count sheet, CCS. The CCS is a count/record of the controlled substance cards, not the individual tablets. […]

• No harm, potential for more than minimal, widespreadF812Sep 11, 2025

  Based on observation, interview, and record review, the facility failed to ensure the resident refrigerator was kept at a temperature at or below 41 degrees Fahrenheit. This applies to all residents in the building.The findings include:The facility's resident roster provided to surveyors on 9/9/25 showed 70 residents residing in the building.On 9/10/25 at 12:54PM, the resident food and drink refrigerator temperature was 44 degrees Fahrenheit. The refrigerator had many items of food and drink located in it.The facility's log for the resident food and drink refrigerator for September 2025 showed temperatures ranging from 44-48 degrees Fahrenheit from 9/1/25-9/10/25.On 9/10/25 at 1:07PM, V2 (Director of Nursing) stated, I believe night shift nurse's check the refrigerator temperature for the… […]

• No harm, potential for more than minimal, widespreadF812Jul 31, 2024

  Based on observation, interview, and record review the facility failed to ensure dishes were submerged in the sanitizing sink for at least 60 seconds and failed to ensure sanitized dishes were handled with clean hands. This has the potential to effect all 66 residents residing in the facility. The findings include: The CMS 671 dated 7/29/24 shows that there are 66 residents residing in the facility. Facility provided Diet Type Report dated 7/30/24 shows that there are no residents that receive a tube feeding and all residents receive food and drinks from the dietary department. 1. […]

• No harm, potential for more than minimal, widespreadF727Aug 17, 2023

  Based on observation, interview, and record review the facility failed to ensure there was a Registered Nurse (RN) working 8 hours a day, 7 days a week. This affects all the residents residing in the facility. The findings include: The facility's CMS 672 Form dated 8/15/23 showed there were 65 residents residing at the facility. The facility's working schedules for 8/1/20 - 8/20/23 showed there was not an RN working at least 8 hours on the weekend of 8/12/23 and 8/13/23. (V2 (DON - Director of Nursing) was handwritten in on the schedule.) On 8/17/23 at 9:36 AM, V2 (DON) said the facility had an average census of 60-65 residents. V2 said she had not been providing direct resident care, except a 4 hour shift at the end of July. […]