Willamette View Health Center

In the surveyor’s words

From the most serious findings on record at Willamette View Health Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF761Mar 12, 2025

  Based on observation, interview and record review it was determined the facility failed to ensure biologicals were stored securely and not accessible to unauthorized individuals for 1 of 1 sampled medication room reviewed for medication storage. This placed residents at risk for unauthorized access to drugs and biologicals. Findings include: The facility's 8/2024 Medication Management Policy & Procedure specified refrigerated medications were kept in a locked, secure refrigerator and all medications were stored in rooms accessible to authorized personnel. On 3/11/25 from 9:05 AM through 10:02 AM the unit's skilled nursing office door was propped open. During this time, various staff members went in and out of the room, and non-staff construction workers walked by the room. […]

• No harm, potential for more than minimal, patternF812Jan 3, 2024

  Based on interview and record review it was determined the facility failed to have a system in place to monitor and document food temperatures for 1 of 1 kitchen reviewed for safe food preparation. This placed residents at risk for food borne illness. Findings include: Review of the facility census indicated two residents resided in the facility. Resident 1 and Resident 2 indicated no concerns regarding food. Review of the residents' medical records revealed no indication of food related illnesses. On 1/3/24 at 10:42 AM during a kitchen observation, Staff 4 (Dining Manager) and Staff 5 (Executive Sous Chef) were asked to provide documentation of the food temperature logs. […]

• No harm, potential for more than minimal, isolatedF684Jun 17, 2026

  Based on interview and record review it was determined the facility failed to contact the physician when indicated by a physician order for 1 of 4 sampled residents (#12) reviewed for medications. This placed residents at risk for lack of needed treatment for a low heart rate. Findings include:Resident 12 was admitted to the facility in 4/2026 with diagnoses including heart failure and dependence on renal dialysis (a medical treatment that removes waste products from the blood when the kidneys are not working properly).The 4/26/26 admission MDS revealed Resident 12 had a BIMS score of 8 indicating the resident had moderate cognitive impairment.The 6/1/26 hospital re-admission physician orders revealed an order to call the covering provider if Resident 12's HR (heart rate) was greater than… […]

• No harm, potential for more than minimal, isolatedF554Mar 12, 2025

  Based on observation, interview and record review it was determined the facility failed to ensure residents were assessed for self administration of medications for 1 of 1 sampled resident (#1) reviewed for medication administration. This placed residents at risk for adverse medication related consequences. Findings include: The facility's 8/2024 Self-Medication policy outlined the following criteria for a resident to self-administer medications: -The resident must successfully pass the Medication Self-administration Safety Screen; -Their primary care physician must approve their request to self-administer medications; and -They must consistently secure their medications out of the reach of others. […]

• No harm, potential for minimal, widespreadF732Mar 12, 2025

  Based on interview and record review it was determined the facility failed to the ensure the Direct Care Staff Daily Report (DCSDR) postings were accurate for 35 of 39 days reviewed for staffing. This placed residents and visitors at risk for inaccurate staffing information. Findings include: The facility's Nursing Staffing Plan policy, dated 1/9/24, indicated that staffing information on the Daily Staff Public Posting form must be an accurate reflection of the actual staff working each shift. […]