Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oregon Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of behavioral issues entered another resident's room and kicked them in the shin, causing pain and redness. The incident was not witnessed by staff but was reported by the injured resident and confirmed by assessment. The aggressive resident had a recent history of illness and increased behavioral symptoms, while the injured resident was cognitively intact and at risk for skin issues.
The facility failed to employ a qualified director of food and nutrition services, affecting all 44 residents receiving meals from the facility's kitchen. The Dietary Manager (DM) was not a Certified Dietary Manager (CDM) as required, despite being in the position since July 2023 and having worked at the facility for ten years. The Registered Dietitian (RD), who consulted monthly, confirmed the DM's lack of qualifications and had recommended certification, but the DM had not pursued it. The Administrator also confirmed the DM's lack of required credentials.
An incident occurred in a facility where a resident with severe cognitive impairment and a history of aggression struck another resident in the dining room. The altercation was triggered when the resident felt trapped, leading to a physical confrontation. Staff intervened promptly, and the incident was reported to the state agency. The facility's investigation noted the resident's history of delusional behaviors due to a UTI and the need for careful monitoring.
A facility failed to ensure proper insulin pen usage for a diabetic resident, as a CMT administered insulin without priming the needle set, contrary to manufacturer's instructions. Additionally, physician orders for a resident with a feeding tube lacked specified volume for Isosource formula, despite repeated requests for clarification by a dietitian.
The facility failed to secure medications and ensure proper administration, as medications were left unattended in front of two residents without self-administration orders. Additionally, an unlocked medication cart was left unattended in the lobby. The Assistant Director of Nursing and the Administrator acknowledged these lapses, which contributed to a deficiency in medication management.
The facility failed to maintain professional standards for food safety, with staff not adhering to proper hand hygiene and food handling practices. Observations included improper glove use, lack of handwashing, and inadequate food storage and labeling. Additionally, the kitchen environment was not kept sanitary, with unclean surfaces and improper dishwashing practices.
The facility did not ensure RN coverage for eight consecutive hours daily, as required. Staffing records for May, June, and July 2024 showed specific days without scheduled RN coverage. The Administrator was aware of these lapses and expected appropriate RN coverage.
Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of dementia-related behaviors entered another resident's room and physically kicked the other resident in the shin. The incident resulted in pain and redness for the resident who was kicked. The event was not witnessed by staff, but was reported by the affected resident and confirmed by a physical assessment that noted redness on the shin. The resident who initiated the altercation had a documented history of dementia, limited mobility, and was identified as an elopement risk and wanderer. Prior to the incident, this resident had exhibited behaviors such as yelling for family and staff, and had recently experienced acute illness, hospitalization, and increased behavioral symptoms upon readmission. The care plan for this resident included monitoring for behaviors that could pose a danger to self or others, as well as interventions for wandering and aggression. The resident who was kicked was cognitively intact, able to voice concerns, and at risk for impaired skin integrity. The incident was reported to facility administration, and staff responded by removing the aggressive resident from the room and providing immediate care to the injured resident. The facility's policies required staff to monitor for and intervene in situations of potential abuse, but the event still occurred, resulting in physical harm to a resident.
Facility Lacks Qualified Dietary Manager
Penalty
Summary
The facility failed to employ a qualified director of food and nutrition services, which had the potential to affect all 44 residents who received meals prepared in the facility's only kitchen. The Dietary Manager (DM) listed in the facility's Key Personnel was not a Certified Dietary Manager (CDM) as required by the job description. The DM had been in the position since July 2023 and had worked at the facility for ten years as a dietary aide. However, she had not completed a dietary manager's course or any course in food safety and management. The Registered Dietitian (RD), who was not full-time and only consulted monthly, confirmed the DM's lack of qualifications. The RD had recommended that the DM complete a course to become a CDM and offered to be her preceptor. Despite these recommendations, the DM had not pursued the necessary certification. The facility's Administrator also confirmed that the DM had not been in the management position for two years and had not completed the required course to meet regulatory standards.
Resident Altercation Due to Cognitive Impairment and Environmental Triggers
Penalty
Summary
The facility failed to protect a resident's right to be free of physical abuse, as evidenced by an incident involving two residents. Resident 16, who has moderate cognitive impairment and a history of verbal and physical outbursts, was involved in an altercation with Resident 40, who has severe cognitive impairment and a history of potential physical aggression related to dementia. The incident occurred in the dining room when Resident 16 attempted to move Resident 40's walker, leading to Resident 40 striking Resident 16 in the face, causing a minor scratch. Resident 40 had been experiencing delusional behaviors due to a urinary tract infection and was on an antibiotic. The altercation was triggered when Resident 40 felt trapped and reacted aggressively. Staff intervened by separating the residents and calling emergency services. Resident 40 was sent to the hospital for evaluation and later returned to the facility. The incident was reported to the state agency within the required timeframe. The facility's investigation revealed that Resident 40 had a history of yelling and threatening other residents but had not previously engaged in physical contact. The incident highlighted the need for careful monitoring of Resident 40's behavior, especially in situations where he might feel confined or threatened. The facility's policy on abuse and neglect emphasizes the prohibition of resident abuse and the requirement to report any incidents that may adversely affect a resident's health or welfare.
Deficiencies in Insulin Administration and Tube Feeding Orders
Penalty
Summary
The facility failed to ensure that staff was knowledgeable about the proper usage of insulin pens for a resident with diabetes. The resident had a physician's order for Humalog insulin, which requires priming the needle set before administration. However, a Certified Medication Technician (CMT) was observed administering the insulin without priming the needle set, indicating a lack of knowledge about the manufacturer's instructions. Both the CMT and the Director of Nursing confirmed the lack of awareness regarding the need to prime the needle set before administering the insulin. Additionally, the facility failed to ensure that physician orders recorded the volume of tube feeding formula for a resident with a feeding tube. The resident's orders for Isosource, a tube feeding formula, did not specify the volume to be administered, despite a consulting dietitian's request for clarification. The Registered Dietitian confirmed that the orders lacked the necessary volume information and had repeatedly asked for clarification over the past year. The facility's Administrator also confirmed the omission in the physician orders.
Medication Management Deficiency Due to Unsecured Storage and Improper Administration
Penalty
Summary
The facility failed to ensure medications were stored securely and administered properly, leading to a deficiency in medication management. Observations revealed that medications were left unattended in pill cups on dining tables in front of two residents, who did not have orders to self-administer their medications. Certified Medication Technician (CMT) A placed the medications on the tables and left the dining room, contrary to facility policy which requires staff to administer and observe medication intake if residents do not have self-administration orders. Resident #1, who was cognitively intact and independent with eating, was left with medications unattended, despite not having a self-administration order. Similarly, Resident #2, who had moderately intact cognition and required assistance with eating, was also left with medications unattended. Both residents had multiple diagnoses and were on various medications, including antidepressants, anticoagulants, and diuretics, which necessitated careful administration and monitoring by staff. Additionally, the facility failed to secure medication carts, as observed with an unlocked cart labeled 'north hall' left unattended in the lobby area outside the nurse's station. The Assistant Director of Nursing and the Administrator both acknowledged that medication carts should be locked when not in use and that it was inappropriate for staff to leave medications unattended in front of residents. These actions and inactions contributed to the deficiency in medication management at the facility.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple observations of improper hand hygiene and food handling practices. Staff members were observed not washing their hands between tasks, using hand sanitizer instead of washing hands, and failing to change gloves between different tasks. Additionally, there were instances where staff did not wash their hands after handling soiled items or after picking up items from the floor, which could lead to cross-contamination. The facility also did not maintain proper food storage and labeling practices. Spices and other food items were found undated and opened, with some being expired. The facility's policy required that food items be dated when opened to ensure they are discarded appropriately, but this was not consistently followed. Furthermore, the facility failed to maintain accurate temperature logs for refrigerators and freezers, which are crucial for ensuring food safety. Sanitation practices in the kitchen were inadequate, with observations of unclean surfaces, lack of sanitizer solution, and improper storage of dishware. The dishwashing machine was not consistently tested for proper sanitation levels, and there were lapses in maintaining a clean and sanitary kitchen environment. Staff interviews revealed a lack of awareness and adherence to the facility's policies on sanitation and food safety, contributing to the deficiencies observed.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week, as required. The facility census was 47, and there was no policy provided regarding RN staffing. A review of the facility's staffing records revealed that there were specific days in May, June, and July 2024 when no RN was scheduled for the required eight consecutive hours. During an interview, the Administrator acknowledged awareness of the lack of RN coverage on certain days and expressed the expectation that the facility should have the required and appropriate RN coverage.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Oregon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tiffany Heights | 12.1 mi | — | 15 | 0 |
| Laverna Manor Health & Rehabilitation | 17.5 mi | — | 19 | 1 |
| Wathena Healthcare & Rehabilitation Center | 17.8 mi | — | 0 | 0 |
| Abundant Acres Care And Rehab | 20.8 mi | — | 0 | 0 |
| Advanced Care Of St Joseph | 21 mi | — | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.