Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around September 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 Nehalem Valley Care Center during CMS and state inspections, most recent first.
A dependent hospice resident with cancer, mixed bladder incontinence, and a coccyx pressure injury was not provided incontinent care or repositioning for about seven hours, despite a care plan requiring checks, changes, and turning at least every two hours. A CNA assigned to the resident acknowledged she only visually checked the brief once, did not change it, and did not reposition the resident due to the resident’s pain, and later wrote a note asking others to keep an LPN from entering the room because care had not been done. Other CNAs and the charge RN reported it was apparent the resident had not been changed, and staff confirmed that standard practice was to provide incontinence care and repositioning per the care plan.
The facility did not provide RN coverage for eight consecutive hours on three reviewed days, as confirmed by staff interviews and daily staffing reports.
The facility did not maintain adequate nursing staff levels, resulting in missed showers, delayed meal service, and prolonged call light response times. Residents reported waiting up to an hour for assistance, and staff confirmed frequent understaffing and difficulty completing basic care tasks in a timely manner.
Staff failed to follow infection control protocols by not donning PPE or performing hand hygiene when entering and exiting rooms of two residents on Contact Precautions, and by not cleaning reusable equipment between uses. Additionally, a CNA was observed wearing the same gloves while assisting multiple residents during meal service, handling food and personal items without changing gloves or performing hand hygiene between tasks.
Two residents were served meals in the dining room using trays covered with black plastic garbage bags, disposable containers, and plastic utensils, while seated with other residents who had standard meal service. Staff initially indicated this was for residents on precautions, but a regional nurse confirmed this was not required by protocol. Both residents expressed a desire to have the same meal service as others.
A resident with dementia was prescribed multiple psychoactive medications, including an antipsychotic, despite showing increasing side effects as measured by AIMS scores. Staff and leadership acknowledged that the antipsychotic was used to address calling out behaviors that were not distressing to the resident, and no comprehensive assessment or gradual dose reduction was performed, with the facility relying on pharmacist reviews instead of their own evaluations.
Staff prepared pureed meals for two residents by adding water to roasted salmon instead of using hot cooking liquid or broth as required by the facility's recipe. The dietary manager confirmed that water should not be used, as it does not provide the necessary nutritional value for residents on pureed diets.
The facility failed to maintain RN coverage for at least eight consecutive hours a day on 41 out of 99 days, risking unmet assessment needs. Additionally, there was no full-time DNS present, leading to confusion and lack of clinical oversight, as confirmed by staff interviews.
Failure to Provide Timely Incontinence Care and Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinent care and repositioning assistance to a dependent resident over a seven-hour period. The resident had diagnoses including cancer and was on hospice, with a care plan indicating mixed bladder incontinence and dependence on staff for toileting. The care plan directed staff to check and change the resident during repositioning, as needed, and throughout the shift, and also documented a pressure injury to the coccyx with instructions for turn/repositioning at least every two hours and more often as needed. On the day in question, a CNA assigned to the resident did not provide incontinent care or repositioning for approximately seven hours of her shift, despite being responsible for these cares. Interviews and the facility’s investigation showed that the CNA acknowledged she had only looked at the resident’s brief early in the shift, thought it appeared dry, and left it unchanged, and that she did not reposition the resident because the resident grimaced in pain when she pulled on the pad. Other CNAs reported that the CNA wrote a note on the CNA message board asking others not to let the nurse enter the resident’s room because the resident had not yet been changed, and that it was obvious to staff later in the shift that the resident had not been changed. The charge nurse became aware near the end of the shift that the resident had not received care, and other CNAs were asked to assist with completing the resident’s cares. Staff interviews confirmed that standard practice was to provide incontinence care and repositioning at least every two hours or according to the care plan, and the administrator acknowledged that the resident was not provided ADL assistance by the CNA for a prolonged period of time.
Failure to Ensure Required RN Coverage
Penalty
Summary
The facility failed to provide registered nurse (RN) coverage for eight consecutive hours per day on three specific days out of forty-three days reviewed. Direct Care Staff Daily Reports showed that there was no RN coverage for the required duration on 2/13/25, 2/15/25, and 6/20/25. This deficiency was confirmed through interviews with the Administrator and Regional Nurse, who acknowledged the lack of RN coverage on the identified days. No additional information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Failure to Provide Sufficient Nursing Staff for Timely Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the care needs of residents in a timely manner across all three resident halls reviewed. Resident Council notes documented missed showers and delays in getting residents to activities and meal service. Review of Direct Care Staff Daily Reports showed that the facility did not meet state minimum CNA staffing requirements on multiple dates. Residents reported significant delays in call light responses, with some waiting up to an hour for assistance, experiencing late showers, and receiving meals late. Some residents had to leave their rooms to seek help due to the lack of available staff. Staff interviews confirmed ongoing staffing shortages, with CNAs frequently assigned to care for 8-12 residents, making it difficult to complete basic care tasks and respond to call lights promptly. Staff described feeling rushed and unable to provide timely showers or assistance, and agency CNAs corroborated that it was common for residents to wait over 20 minutes for call lights to be answered. The facility administrator acknowledged the staffing concerns and the impact on timely resident assistance.
Failure to Implement Proper Infection Control and Hand Hygiene Practices
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices, specifically regarding hand hygiene and the use of personal protective equipment (PPE) for residents on Contact Precautions. Staff were observed entering and exiting rooms of residents on Contact Precautions without donning appropriate PPE or performing hand hygiene, despite clear signage and facility policy. In one instance, a CNA entered a resident's room twice without PPE and did not perform hand hygiene upon exit. In another case, an LPN entered a resident's room without PPE, used a reusable blood pressure device without cleaning it afterward, and placed it on a medication cart without a barrier. Both staff members acknowledged their failure to follow proper procedures, and facility leadership confirmed that staff were confused about the differences between Enhanced Barrier Precautions and Contact Precautions. Additionally, during meal service in the main dining room, a CNA was observed wearing the same gloves while assisting multiple residents, handling food items, touching personal items such as a phone, and performing various tasks without changing gloves or performing hand hygiene between residents. The CNA admitted to only changing gloves and performing hand hygiene twice during meal service and recognized that hand hygiene should have been performed after touching personal items. Facility leadership confirmed that staff were expected to perform hand hygiene between assisting residents in the dining room.
Failure to Provide Dignified Dining Experience for Residents on Precautions
Penalty
Summary
The facility failed to ensure a dignified dining experience for two residents who were observed receiving their meals in the dining room with black plastic garbage bags covering their trays. The meals were served in disposable clamshell containers, with fruit in disposable paper soup cups, and plastic utensils provided, while the residents sat at a communal table with others who did not have similar arrangements. Staff explained that these trays were for individuals on precautions, but the regional nurse later clarified that the use of plastic bags, clamshell containers, and disposable utensils was not part of the protocol for residents on contact precautions. Both affected residents expressed a preference for having a normal tray and being treated like the other residents.
Failure to Assess and Address Unnecessary Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that a resident with dementia was free from unnecessary use of antipsychotic medication. The resident was admitted with diagnoses including a stage four pressure ulcer and dementia, and was prescribed multiple psychoactive medications, including quetiapine, trazodone, venlafaxine, Namenda, and hydroxyzine. Despite the presence of symptoms and side effects associated with psychoactive medication use, as evidenced by increasing Abnormal Involuntary Movement Scale (AIMS) scores, the facility did not adequately assess the continued need for antipsychotic medication. The physician was notified of certain symptoms and reduced the dose of venlafaxine, but did not address the use of quetiapine. The Psychotropic Committee did not order additional gradual dose reductions (GDRs) or assess the appropriateness of continued antipsychotic use despite adverse side effects. Observations and staff interviews indicated that the resident did not exhibit negative behaviors or signs of distress, and staff reported that calling out behaviors had lessened and were not distressing to the resident. However, the facility relied on pharmacist reviews rather than conducting their own assessments for antipsychotic medication use. Facility leadership acknowledged that antipsychotic medication was prescribed to address calling out behaviors that were disturbing to others, but not distressing to the resident, and admitted that a comprehensive risk/benefit assessment should have been completed in light of the adverse side effects.
Improper Preparation of Pureed Foods Using Water Instead of Nutritive Liquids
Penalty
Summary
The facility failed to ensure that pureed foods were prepared using methods that conserved nutritive value and flavor for residents requiring pureed diets. During two observed meals, a cook was seen adding approximately 6-8 ounces of water to roasted salmon while preparing a pureed meal for a resident, instead of using hot cooking liquid or hot broth as specified in the facility's recipe. The cook confirmed the use of water, and the dietary manager later stated that water should not be used for pureed meals, emphasizing that a liquid with more nutritional value was required. This practice resulted in the preparation of pureed food that did not meet the facility's standards for nutritional value and flavor.
Deficiency in RN Coverage and Lack of Full-Time DNS
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least eight consecutive hours a day, as required, for 41 out of 99 days reviewed. This deficiency was confirmed by the facility's administrator, who acknowledged the absence of RN coverage on the specified dates. The lack of consistent RN presence placed residents at risk for unmet assessment needs, as there was no qualified nursing staff available to address potential health concerns during these periods. Additionally, the facility did not have a designated full-time Director of Nursing Services (DNS) for an extended period. Staff interviews revealed that the previous DNS had left in October 2024, and since then, an RN consultant was working remotely as the DNS, but was not physically present in the facility. This absence of a full-time DNS led to confusion among staff, who reported difficulties in identifying leadership and obtaining guidance for clinical questions. The lack of on-site nursing oversight further compromised the facility's ability to manage residents' clinical needs effectively.
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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 Wheeler
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Clatsop Care Center | 34.7 mi | — | 6 | 0 |
| Marquis Forest Grove Post Acute Rehab | 39.9 mi | — | 5 | 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.