Oregon Veterans Home

In the surveyor’s words

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

• Actual harm, isolatedF600Jun 26, 2026

  Based on observation, interview and record review it was determined the facility failed to protect the resident's right to be free from physical abuse for 1 of 10 sampled residents (#26) reviewed for abuse. This placed residents at risk for physical harm. Findings include:The facilities Resident Freedom from Abuse Policy revised 10/7/24 stated the following:-The facility would prevent and prohibit abuse and ensure residents were provided with a safe environment.-Resident-to-Resident abuse included the willful or non-willful infliction of injury resulting in physical harm.Resident 26 was admitted to the facility in 6/2023 with diagnoses including depression.Resident 26's 11/30/25 Annual MDS revealed she/he had a BIMS of 14, which indicated the resident was cognitively intact. […]

• No harm, potential for more than minimal, patternF684Jun 26, 2026

  Based on interview and record review it was determined the facility failed to administer medications according to physician orders and failed to notify the physician of continued missed medication for 2 of 5 sampled residents (#s 62 and 115) reviewed for medications. This placed residents at risk for adverse side effects of medications and worsening medical conditions. Findings include: 1. Resident 62 was admitted to the facility in 11/2023 with diagnoses including dementia with behavioral disturbances. Resident 62's 6/5/26 care plan indicated to administer medications as ordered, and document for effectiveness or side effects. […]

• No harm, potential for more than minimal, patternF761Jun 26, 2026

  Based on observation, interview, and record review it was determined the facility failed to ensure proper labeling of biologicals for 2 of 7 treatment carts and failed to ensure treatment carts were properly secured during observations. This placed residents at risk for receiving medications with reduced efficacy and unauthorized access to medications. Findings include:1. On 6/24/26 at 12:27 PM, one open Lantus insulin pen was observed in the [NAME] Unit treatment cart, it was not labeled with an open date.On 6/24/26 at 12:27 PM, Staff 3 (RN) acknowledged the insulin pen was open and not labeled with an open date.On 6/26/26 at 9:30 AM, Staff 2 (Assistant DNS) stated the expectation was for open insulin to be labeled with an open date.2. […]

• No harm, potential for more than minimal, patternF641Mar 14, 2025

  Based on interview and record review it was determined the facility failed to accurately code MDS assessments for 5 of 5 sampled residents (#s 10, 23, 84, 97, and 103) reviewed for use of anticoagulants. This placed residents at risk for inaccurate medication assessments. Findings include: 1. Resident 10 admitted to the facility in 2018 with diagnoses including dementia and anxiety. The 10/29/24 and 1/21/25 Quarterly MDSes indicated Resident 10 received an anticoagulant medication. No evidence was found in Resident 10's clinical record to indicate she/he received an anticoagulant medication. On 3/14/25 at 9:40 AM, Staff 6 RNCM and at 11:15 AM, Staff 2 (DNS) were interviewed. Staff 6 stated she completed portions of the the MDS, including section N for medications. […]

• No harm, potential for more than minimal, patternF688Oct 7, 2022

  Based on interview and record review it was determined the facility failed to provide ROM and RA services for 4 of 4 sampled residents (#s 7, 72, 83 and 85) reviewed for positioning and mobility. This placed residents at risk for a decline in mobility. Findings include: 1. Resident 7 was admitted to the facility in 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Facility Restorative Care Referral form (generated by the therapy department PT) dated 1/17/22 indicated the resident was to have an RA walking program to maintain mobility. The resident was a contact guard assist (CGA) with walking and needed cues for balance, steering her/his front wheel walker (FWW) and safety. […]