BLUE MOUNTAIN CARE CENTER
Government - Hospital district
40 Beds
Independent
Data: November 2025
Trust Grade
50/100
#81 of 127 in OR
Last Inspection: August 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Blue Mountain Care Center has a Trust Grade of C, which means it is average and ranks in the middle of the pack, indicating that while it is not the worst option, it is not particularly strong either. It holds the #81 position out of 127 nursing homes in Oregon, placing it in the bottom half of state facilities, but it is the only facility in Grant County, meaning there are no local competitors. The facility is improving, with issues decreasing from 11 in 2023 to 8 in 2024. Staffing is a concern, rated only 1 out of 5 stars, but with a 0% turnover rate, suggesting staff members are remaining in place. Notably, there have been no fines recorded, which is a positive indicator. However, there are significant weaknesses to consider. Recent inspections revealed multiple concerns, including a failure to maintain a medication error rate below 5%, with a reported rate of 19%, which poses risks for residents' health. Additionally, there were no monthly pharmacy reviews conducted for certain residents, which could lead to adverse effects from medications. Lastly, staff members experienced delays in accessing the medical director during emergencies, indicating potential gaps in urgent care response. Overall, while Blue Mountain Care Center has some positive attributes, families should weigh these concerns carefully when considering care options.
- Trust Score
- C
- In Oregon
- #81/127
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- Turnover data not reported for this facility.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Oregon facilities.
- Skilled Nurses ○ Average
- RN staffing data not reported for this facility.
- Violations ⚠ Watch
- 28 deficiencies on record. Higher than average. Multiple issues found across inspections.
50/100
Bottom 37%
No red flags
11 → 8 violations
★★☆☆☆
2.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2023: 11 issues
2024: 8 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
2-Star Overall Rating
Below Oregon average (3.0)
Below average - review inspection findings carefully
The Ugly 28 deficiencies on record
Aug 2024
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to ensure professional standards were followed for 1 ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to ensure professional standards were followed for 1 of 1 RN (Staff 2) reviewed for medications and pressure ulcers. This placed residents at risk for adverse medication reactions and worsening of wounds. Findings include:
The Oregon State Board of Nursing Scope of Practice Standards for Registered Nurses (OAR [PHONE NUMBER]) outlined standards related to the Registered Nurse's responsibility for nursing practice implementation. Applying nursing knowledge . the Registered Nurse shall implement the plan of care by:
- Implementing treatments and therapy, appropriate to the context of care, including emergency measures, interpretation of medical orders, medication administration, independent nursing activities, nursing, medical and interdisciplinary orders, health teaching and health counseling;
- Documenting nursing interventions and responses to care in an accurate, timely, thorough, and clear manner.
The Oregon State Board of Nursing Conduct Derogatory to the Standards of Nursing (OAR [PHONE NUMBER]) outlined nurses, regardless of role, whose behavior fails to conform to the legal standard and accepted standards of the nursing profession, or who may adversely affect the health, safety, and welfare of the public, may be found guilty of conduct derogatory to the standards of nursing. Such conduct shall include, but is not limited to, the following:
- Failing to develop, implement and/or follow through with the plan of care;
- Accepting an assignment when individual competency necessary to safely perform the assignment has not been established or maintained;
- Entering inaccurate, incomplete, falsified, fabricated or altered documentation into a health record.
1. Resident 164 re-admitted to the facility on [DATE] with diagnoses including post-surgical care for a toe amputation.
On 8/13/24 at 3:27 PM Staff 2 (DNS) stated he received Resident 164's admission physician orders on 8/2/24 and did not implement the orders prior to leaving the facility for the day.
On 8/15/24 at 3:49 PM Staff 1 (Administrator) stated on 8/2/24 around 9:00 AM she requested Staff 2 to review Resident 164's admission physician orders prior to the resident's arrival and to implement the orders. Staff 1 further stated Staff 2 left the building on 8/2/24 around 3:00 PM and she was unaware admission physician orders were not implemented. Staff 1 acknowledged admission physician orders were not implemented for three days after Resident 164 admitted to the facility.
Refer to F684.
2. Resident 8 admitted to the facility on [DATE] with diagnoses including diabetes and a sacral fracture.
On 8/10/24 Resident 8 was identified to have a new wound to her/his left buttock.
On 8/14/24 at 12:34 PM Staff 2 (DNS) stated he was hired on 7/26/24 at the facility. Staff 2 stated Staff 3 (RNCM) completed skin assessments on 7/30/24, prior to her leaving for vacation and he had not completed skin assessments for any resident.
On 8/15/24 at 11:59 AM Staff 2 assessed Resident 8's left buttock wound (five days after wound was identified.)
On 8/15/24 at 3:18 PM Staff 3 (RNCM) stated she was in charge of completing skin assessments but had been on vacation since the end of July. Staff 3 further stated floor nurses did not usually complete skin assessments and the expectation was for Staff 2 to complete skin assessments.
Refer to F686.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review it was determined the facility failed to provide nail care to dependent residents for 2 of 2 sample residents (#s 10 and 11) reviewed for ADLs. This ...
Read full inspector narrative →
Based on observation, interview, and record review it was determined the facility failed to provide nail care to dependent residents for 2 of 2 sample residents (#s 10 and 11) reviewed for ADLs. This placed residents at risk for lack of grooming and skin impairments. Findings include:
1. Resident 10 admitted to the facility in 2021 with diagnoses including kidney disease.
The 7/26/21 Care Plan indicated Resident 10 required ADL assistance by staff for personal hygiene.
Review of Resident 10's clinical medical record revealed no documented evidence for when the resident's nail care was to be provided.
Observations made on 8/13/24 at 9:20 AM and on 8/14/24 at 9:30 AM revealed Resident 10 with long fingernails. Some of the fingernails were curved down, touching the nail bed. Resident 10 was unable to state when her/his fingernails were last trimmed.
On 8/14/24 at 9:24 AM Staff 6 (CNA) stated resident nail care was to be done on shower days and as needed. Staff 6 stated nail care was documented in Tasks under personal hygiene and there was no specific place to document when nail care was completed. Staff 6 acknowledged Resident 10's nails were long and curved down.
On 8/14/24 at 9;43 AM Staff 2 (DNS) stated the expectation was for nursing staff to complete nail care even for non-diabetic residents. Staff 2 acknowledged Resident 10's nails were long, curved and needed to be trimmed.
2. Resident 11 admitted to the facility in 2023 with diagnoses including dementia with moderate cognitive impairment.
The 8/29/23 Care Plan indicated Resident 11 required assistance with ADL care related to her/his dementia. Interventions included to check nail length and trim and clean on bath days and as needed.
Review of Resident 11's clinical record revealed no documented evidence for when the resident's nail care was to be provided.
On 8/13/24 at 9: 20 AM Resident 11 stated her/his fingernails were not trimmed often enough and could not recall the last time her/his nails were trimmed. Resident 11 stated her/his fingernails were much longer than she/he was use too or normally had them. Resident 11 stated staff had not asked if she/he wanted her/his fingernails trimmed.
On 8/14/24 at 9:24 AM Staff 6 (CNA) stated resident nail care was to be done on shower days and as needed. Staff 6 stated nail care was documented in Tasks under personal hygiene and there was no specific place to document when nail care was completed. Staff 6 acknowledged Resident 11's nails were on the longer side and staff were to be checking resident fingernails routinely.
On 8/14/24 at 9:43 AM Staff 2 (DNS) stated the expectation was for nursing staff to complete nail care even for non-diabetic residents. Staff 2 acknowledged Resident 11's nails were long and needed to be trimmed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to implement physician orders upon admission for 1 of...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to implement physician orders upon admission for 1 of 1 sampled residents (#164) reviewed for medications. This placed residents at risk for adverse medication reactions. Findings include:
Resident 164 re-admitted to the facility on [DATE] with diagnoses including post-surgical care for a toe amputation.
The 8/2/24 hospital discharge orders indicated Resident 164 was to receive the following medications:
-doxycycline (an antibiotic medication) 100 mg; 1 tablet BID. 8/3/24 PM dose was missed.
-losartan (a hypertension medication) 25 mg; 1 tablet BID. 8/3/24 PM dose was missed.
-pravastatin (a cholesterol medication) 40 mg; 1 tablet one time a day. 8/3/24 dose was missed.
The MAR and 8/3/24 progress note indicated Resident 164 did not receive one dose of doxycycline, one dose of losartan, and one dose of pravastatin.
An 8/3/24 at 4:58 PM progress note revealed Staff 5 (RN) was unable to resume many meds and documented in the progress note the medications given to the resident.
An 8/4/24 at 6:10 AM progress note revealed there were no orders in the resident's chart.
On 8/13/24 at 3:27 PM Staff 2 (DNS) stated he received Resident 164's admission physician orders on 8/2/24 and did not implement the orders prior to leaving the facility for the day.
On 8/15/24 at 3:49 PM Staff 1 (Administrator) stated on 8/2/24 around 9:00 AM she requested Staff 2 to review Resident 164's admission physician orders prior to the resident's arrival and to implement the orders. Staff 1 further stated Staff 2 left the building on 8/2/24 around 3:00 PM and she was unaware admission physician orders had not been implemented. Staff 1 acknowledged admission physician orders were not implemented for three days after Resident 164 admitted to the facility and did not receive the identified medications.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to initially assess and monitor pressure ulcers for 2 of 2 sampled residents (#s 6 and 8) reviewed for pressure ulcers. This ...
Read full inspector narrative →
Based on interview and record review it was determined the facility failed to initially assess and monitor pressure ulcers for 2 of 2 sampled residents (#s 6 and 8) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers and unassessed treatment needs. Findings include:
1. Resident 8 admitted to the facility on 5/2024 with diagnoses including diabetes and a sacral fracture.
The 5/20/24 admission Nursing Database indicated Resident 8 did not have any wounds present.
The 5/20/24 care plan indicated the resident had a potential impairment to skin integrity related to diabetes and fragile skin. Interventions included to encourage and assist resident to change positions frequently; notify nurse of new skin issues; and follow facility protocols for treatment of injury.
The 8/2024 TAR revealed the facility implemented a standing order for wound care on 8/10/24 for a wound to Resident 8's left buttock.
The 8/11/24 at 4:36 AM progress note indicated wound care was completed to an open area on Resident 8's left buttock. It was noted there was no drainage, the area was cleaned and covered.
On 8/14/24 at 12:34 PM Staff 2 (DNS) stated he was hired on 7/26/24 at the facility. Staff 2 stated Staff 3 (RNCM) completed skin assessments on 7/30/24, prior to her leaving for vacation and he had not completed skin assessments for any resident.
The 8/15/24 at 11:59 AM progress note revealed Staff 2 assessed Resident 8's left buttock wound (five days after the wound was identified.) The progress note indicated Resident 8 had a Stage 2 pressure ulcer on the left inner gluteal (muscles that make up the buttock area) that measured 1.2 inches long, .5 inches wide, and 0 inches deep with no visual drainage or odor. Four Stage 2 pressure ulcers to the left forearm were also identified and measured.
The 8/15/24 at 12:49 PM Weekly Wound Observation Tool completed by Staff 2 indicated Resident 8 had a Stage 2 pressure ulcer on the left gluteal and left forearm, slough tissue was present (yellow/white material in the wound bed) and the wounds were facility acquired on 5/15/24. The measurements were 20 mm long, 13 mm wide, 02 mm deep and had minimal drainage with a slight odor. The measurements and wound appearance did not identify which wound it was for.
On 8/15/24 at 2:47 PM Staff 2 was asked about the discrepancy of wound measurements between Resident 8's progress note and the Weekly Wound Observation Tool note. Staff 2 stated the 8/15/24 at 11:59 AM progress note was the most accurate. Staff 2 stated he had wound care training, but it had been about ten years since he had assessed wounds.
On 8/15/24 at 3:18 PM Staff 3 (RNCM) stated she was in charge of completing skin assessments but had been on vacation since the end of July. Staff 3 further stated floor nurses did not usually complete skin assessments and the expectation was for Staff 2 to complete skin assessments.
2. Resident 6 readmitted to the facility in 2023 with diagnoses including a Stage 4 pressure ulcer of the sacral region.
On 8/14/24 a review of Resident 6's clinical record indicated the Weekly Wound Observation Tool was completed on 7/30/24. There was no indication additional weekly wound assessments were completed after 7/30/24.
On 8/14/24 at 11:51 AM Staff 2 (DNS) stated Staff 3 (RNCM) completed skin assessments on 7/30/24, prior to her leaving for vacation and he had not completed skin assessments for Resident 6.
The 8/15/24 12:16 PM progress note by Staff 5 (RN) indicated Resident 6 had a dressing change to the coccyx and the wound measured 2.4 cm long, 1.2 cm wide and 1 cm deep.
The 8/15/24 2:01 PM Weekly Wound Observation Tool completed by Staff 5 indicated Resident 6 had a Stage 4 pressure ulcer on the coccyx measured 20 mm long, 20 mm wide, and 1 mm deep.
On 8/15/24 at 2:34 PM Staff 5 (RN) was asked about the discrepancy of wound measurements between Resident 6's progress note and the Weekly Wound Observation Tool note. Staff 5 reviewed the progress note and Weekly Wound Observation Tool and stated she completed the dressing change and measurements for Resident 6. Staff 5 then reviewed her handwritten notes and stated the measurements of the wound from her notes were 19 cm long, 20 cm wide, and 0.9 cm deep. Staff 5 acknowledged there were discrepancies between the progress note, the Weekly Wound Observation Tool note and her handwritten notes. Staff 5 stated she had not completed wound measurements at this facility previously.
On 8/15/24 at 3:18 PM Staff 3 (RNCM) stated she was in charge of completing skin assessments but had been on vacation since the end of July. Staff 3 further stated floor nurses did not usually complete skin assessments and the expectation was for Staff 2 to complete skin assessments.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to obtain ordered medications timely for 2 of 6 sampl...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to obtain ordered medications timely for 2 of 6 sampled residents (#s 1 and 7) reviewed for medications. This placed residents at risk for not receiving prescribed medications. Findings include:
1. Resident 1 admitted to the facility in 2018 with diagnoses including chronic kidney disease.
The 8/9/24 physician order indicated Resident 1 had a UTI and to start Keflex (antibiotic) 500 mg TID for seven days.
The 8/2024 MAR indicated Resident 1 did not receive Keflex on the following dates and times:
-8/10/24 8:00 PM
-8/11/24 7:00 AM
-8/11/24 12:00 PM
-8/11/24 8:00 PM
-8/12/24 7:00 AM
-8/12/24 12:00 PM
On 8/15/24 at 12:29 PM Staff 2 (DNS) acknowledged Resident 1 did not receive Keflex as ordered on the identified dates. Staff 2 was observed to check the electronic medication dispensing system for availability of Keflex and stated he was unsure of how to check for inventory and availability of medication. Staff 2 stated he thought the medications were automatically refilled by the pharmacy. Staff 1 (Administrator) stated there was a breakdown in the reordering process for medications by nursing staff.
2. Resident 7 admitted to the facility in 2023 with diagnoses including diabetes.
The 8/12/24 hospital discharge summary indicated Resident 7 had a UTI and was to start cephalexin (antibiotic) 500 mg four times daily for 7 days.
The 8/2024 MAR indicated Resident 7 was to receive cephalexin at 7:00 AM, 12:00 PM, 5:00 PM and 9:00 PM. Resident 7 did not receive the first dose of cephalexin until 8/13/24 at 5:00 PM.
On 8/15/24 at 12:29 PM Staff 2 (DNS) acknowledged Resident 7 readmitted to the facility on [DATE] and did not receive the first dose of cephalexin until 8/13/24 at 5:00 PM. Staff 2 was observed to check the electronic medication dispensing system for availability of cephalexin and stated he was unsure of how to check for inventory and availability of medication. Staff 2 stated he thought the medications were automatically refilled by the pharmacy. Staff 1 (Administrator) stated there was a breakdown in the reordering process for medications by nursing staff.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to address pharmacist recommendations in a timely manner for 3 of 5 sampled residents (#s 6, 8 and 12) reviewed for unnecessa...
Read full inspector narrative →
Based on interview and record review it was determined the facility failed to address pharmacist recommendations in a timely manner for 3 of 5 sampled residents (#s 6, 8 and 12) reviewed for unnecessary medications. This placed residents at risk for unnecessary medication administration. Findings include:
1. Resident 8 admitted to the facility on 5/2024 with diagnoses including depression.
A 7/8/24 Pharmacy Review indicated Resident 8 received mirtazapine (an antidepressant) 7.5 mg at bedtime. The recommendation was to discontinue this medication.
On 8/6/24, (29 days later), the physician agreed with the pharmacy recommendation.
A review of the 8/2024 MAR indicated Resident 8 received the last dose of mirtazapine 7.5 mg at bedtime on 8/6/24.
On 8/15/24 at 3:11 PM Staff 3 (RNCM) stated the expectation was for the physician to address the pharmacy recommendations within two weeks and implement the recommendations. Staff 3 acknowledged Resident 8 had a pharmacy recommendation on 7/8/24 and it was not signed by the physician until 8/6/24.
2. Resident 6 readmitted to the facility in 2023 with diagnoses including anxiety disorder.
Resident 6's 6/26/24 pharmacy recommendation indicated the following:
-Resident 6 received trazodone (antidepressant) 100 mg at bedtime, diazepam (antianxiety) 2 mg at bedtime and duloxetine (antidepressant) 60 mg daily.
-Consider changing diazepam to lorazepam 1 mg at bedtime. Diazepam is long lasting and considered potentially inappropriate medication for use in older adults and should be avoided due to the high risk of adverse reactions.
The recommendation was not signed by the physician until 7/31/24 (35 days later) and indicated to discontinue diazepam and start lorazepam 1 mg QHS PRN.
On 8/14/24 at 10:54 AM and 8/15/24 at 3:18 PM Staff 3 (RNCM) stated the expectation was for the physician to follow up on pharmacy recommendations within two weeks. Staff 3 acknowledged Resident 6 had a pharmacy recommendation on 6/26/24 and it was not signed by the physician until 7/31/24.
3. Resident 12 admitted to the facility in 2024 with diagnoses including heart disease, bipolar and depression.
A 6/26/24 Pharmacy Review indicated Resident 12 received Quetiapine (antipsychotic), Citalopram (anti-depressant) and trazodone (anti-depressant). The medications had a potential to prolong the QT interval (heart rhythm) and put the resident at risk for torsade de pointes (fast heart rhythm), ventricular tachycardia (quick beats in the lower heart chambers) and ventricular fibrillation (fast, inadequate heartbeat). A recommendation to monitor for heart palpitations, shortness of breath, chest pain, lightheadedness and fainting as well as an EKG every six months was recommended. On 7/3/24 the physician responded and agreed with the recommendations.
Review of Resident 12's clinical record revealed no documented evidence the resident's recommendations were addressed.
On 8/15/24 at 3:15 PM Staff 3 (RNCM) acknowledged she had not followed up with the physician and addressed the agreed upon pharmacy recommendations.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to ensure medical records were accurate for 2 of 2 sampled residents (#s 6 and 8) reviewed for pressure ulcers. This placed r...
Read full inspector narrative →
Based on interview and record review it was determined the facility failed to ensure medical records were accurate for 2 of 2 sampled residents (#s 6 and 8) reviewed for pressure ulcers. This placed residents at risk for inaccurate wound measurements. Findings include:
1. Resident 8 admitted to the facility on 5/2024 with diagnoses including diabetes and a sacral fracture.
The 8/15/24 at 11:59 AM progress note by Staff 2 (DNS) indicated Resident 8 had a Stage 2 pressure ulcer on the left inner gluteal (muscles that make up the buttock area) that measured 1.2 inches long, .5 inches wide, and 0 inches deep with no visual drainage or odor. Four Stage 2 pressure ulcers to the left forearm were also identified and measured.
The 8/15/24 at 12:49 PM Weekly Wound Observation Tool completed by Staff 2 indicated Resident 8 had a Stage 2 pressure ulcer on the left gluteal and left forearm, slough tissue was present (yellow/white material in the wound bed), and the wounds were facility acquired on 5/15/24. The measurements were 20 mm long, 13 mm wide, 02 mm deep and had minimal drainage with a slight odor. The measurements and wound appearance did not identify which wound it was for.
On 8/15/24 at 2:47 PM Staff 2 was asked about the discrepancy of wound measurements between Resident 8's progress note and the Weekly Wound Observation Tool note. Staff 2 stated the 8/15/24 at 11:59 AM progress note was the most accurate.
2. Resident 6 readmitted to the facility in 2023 with diagnoses including a Stage 4 pressure ulcer of the sacral region.
The 8/15/24 12:16 PM progress note by Staff 5 (RN) indicated Resident 6 had a coccyx wound that measured 2.4 cm long, 1.2 cm wide and 1 cm deep.
The 8/15/24 2:01 PM Weekly Wound Observation Tool indicated Resident 6 had a Stage 4 pressure ulcer on the coccyx that measured 20 mm long, 20 mm wide, and 1 mm deep.
On 8/15/24 at 2:34 PM Staff 5 (RN) was asked about the discrepancy of wound measurements between Resident 6's progress note and the Weekly Wound Observation Tool note. Staff 5 reviewed the progress note and Weekly Wound Observation Tool and stated she completed the dressing change and measurements for Resident 6. Staff 5 then reviewed her handwritten notes and stated the measurements of the wound from her notes were 19 cm long, 20 cm wide, and 0.9 cm deep. Staff 5 acknowledged there were discrepancies between the progress note, the Weekly Wound Observation Tool note and her handwritten notes.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review it was determined the facility failed to maintain a medication error rate of less than five percent. There were five errors in 26 opportunities result...
Read full inspector narrative →
Based on observation, interview and record review it was determined the facility failed to maintain a medication error rate of less than five percent. There were five errors in 26 opportunities resulting in a 19 percent error rate. This placed residents at risk for adverse medication side effects. Findings include:
1. Resident 164 admitted to the facility in 8/2024 with diagnoses including diabetes.
The 6/5/24 physician order indicated Resident 164 was to receive Novolin R (insulin) seven units before meals.
The manufacturer instructions for Novolin R indicated to prime the insulin pen with two units prior to drawing up the insulin for administration.
On 8/13/24 at 12:18 PM Staff 4 (RN) was observed to administer seven units of Novolin R via insulin pen to Resident 164. Staff 4 did not prime the insulin pen with two units prior to drawing up the insulin for administration.
On 8/13/24 at 12:55 PM Staff 4 acknowledged she did not prime the insulin pen prior to administration and stated she was not aware the Novolin R insulin pen needed to be primed.
2. Resident 8 readmitted to the facility in 2024 with diagnoses including diabetes.
The 7/11/24 and 8/2/24 physician orders indicated Resident 8 was to receive the following:
-insulin lispro five units before meals.
-insulin lispro sliding scale if CBG: 0-149 zero units and 250-299 five units before meals.
The manufacturer instructions for the insulin lispro pen indicated to prime the insulin pen with two units prior to drawing up the insulin for administration.
On 8/13/24 at 12:37 PM Staff 4 (RN) was observed to check Resident 8's CBG and it was 254. Staff 4 was observed to administer ten units of insulin lispro via insulin pen to Resident 8. Staff 4 did not prime the insulin pen with the two units recommended by the manufacturer prior to administering the insulin lispro.
On 8/13/24 at 12:55 PM Staff 4 acknowledged she did not prime the insulin pen prior to administration and stated she was not aware the insulin lispro pen needed to be primed.
On 8/15/24 at 8:16 AM Staff 5 (RN) was observed to check Resident 8's CBG and it was 117. Staff 5 was observed to administer five units of insulin lispro via insulin pen to Resident 8. Staff 5 did not prime the insulin pen with the two units recommended by the manufacturer prior to administering the insulin lispro.
On 8/15/24 at 8:29 AM Staff 5 acknowledged she did not prime the insulin pen prior to administration and stated she was not aware the insulin lispro pen needed to be primed.
3. Resident 1 admitted to the facility in 2018 with diagnoses including chronic kidney disease. The 7/19/24 diagnoses were updated to included diabetes.
The 8/2/24 physician order indicated Resident 1 was to receive Lantus (insulin) 15 units once daily.
The manufacturer instructions for the Lantus insulin pen indicated to prime the insulin pen with two units prior to drawing up the insulin for administration.
On 8/15/24 at 7:48 AM Staff 5 (RN) was observed to administer 15 units of Lantus insulin via insulin pen to Resident 1. Staff 5 did not prime the insulin pen with the two units recommended by the manufacturer prior to administering the Lantus insulin.
On 8/15/24 at 8:29 AM Staff 5 acknowledged she did not prime the insulin pen prior to administration and stated she was not aware the Lantus insulin pen needed to be primed.
4. Resident 3 admitted to the facility in with diagnoses including atrial fibrillation (irregular heart rhythm).
The 7/31/24 physician order indicated Resident 3 was to receive diltiazem (antiarrhythmic heart medication) 240 mg once daily for atrial fibrillation and to hold the medication if the blood pressure was less than 100/60 or the heart rate was less than 60.
On 8/15/24 at 8:14 AM Staff 5 (RN) was observed to administer morning medications to Resident 3. Staff 5 stated Resident 3's blood pressure and heart rate were taken at approximately 7:10 AM and she/he had a blood pressure of 127/63 and a pulse of 70. Staff 5 stated she held the diltiazem even though the blood pressure and pulse were within the parameters to administer the medication.
May 2023
11 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0568
(Tag F0568)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to provide quarterly statements in writing of Personal Incidental Funds (PIF) for 2 of 2 sampled residents (#s 3 and 5) revie...
Read full inspector narrative →
Based on interview and record review it was determined the facility failed to provide quarterly statements in writing of Personal Incidental Funds (PIF) for 2 of 2 sampled residents (#s 3 and 5) reviewed for PIFs. This placed residents at risk of being uninformed of financial statements. Findings include:
1. Resident 3 admitted to the facility in 2018 with diagnoses including dementia.
On 5/15/23 at 8:47 AM Witness 1 (Complainant) stated the facility was in charge of Resident 3's finances including managing her/his PIF (Personal Incident Fund) of 30 dollars a month. Witness 1 stated she used to receive quarterly statements of Resident 3's PIF account but not longer received the statement and was unaware of how much Resident 3 had in her/his account.
On 5/15/23 at 12:08 PM Staff 3 (Social Services) stated she was unsure if a quarterly statement was sent of Resident 3's PIF account. Staff 3 stated the account was managed by Staff 4 (Accountant).
On 5/15/23 at 1:28 PM Staff 4 stated she managed Resident 3's finances including her/his PIF account. Staff 4 stated she did not sent out quarterly statements related to Resident 3's PIF account and was not aware it was required.
2. Resident 5 admitted to the facility in 2019 with diagnoses including dementia.
On 5/15/23 at 8:47 AM Witness 1 (Complainant) stated the facility was in charge of Resident 5's finances including managing her/his PIF (Personal Incident Fund) of 30 dollars a month. Witness 1 stated she used to receive quarterly statements of Resident 5's PIF account but not longer received the statement and was unaware of how much Resident 5 had in her/his account.
On 5/15/23 at 12:08 PM Staff 3 (Social Services) stated she was unsure if a quarterly statement was sent of Resident 5's PIF account. Staff 3 stated the account was managed by Staff 4 (Accountant).
On 5/15/23 at 1:28 PM Staff 4 stated she managed Resident 5's finances including her/his PIF account. Staff 4 stated she did not sent out quarterly statements related to Resident 5's PIF account and was not aware it was required.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to complete comprehensive assessments for 1 of 5 sampled residents (# 6) reviewed for medication. This placed residents at ri...
Read full inspector narrative →
Based on interview and record review it was determined the facility failed to complete comprehensive assessments for 1 of 5 sampled residents (# 6) reviewed for medication. This placed residents at risk for unassessed needs. Findings include:
Resident 6 admitted to the facility in 3/2023 with diagnoses including anxiety disorder and depressive disorder.
The 4/2023 MARs indicated Resident 6 received the following medications:
-trazodone (antidepressant medication) once daily;
-bupropion (antidepressant medication) once daily;
-buspirone (antianxiety medication) BID.
The 4/7/23 Psychotropic Drug Use CAA was blank. The CAA failed to identify resident behaviors, history of the use of psychotropic medications, current psychotropic medication use, interventions or monitoring in place related to the resident's use of the medications.
On 5/16/23 at 10:32 AM Staff 1 (Administrator) acknowledged Resident 6's Psychotropic Drug Use CAA was blank and was not comprehensive as identified.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to assess and treat diabetic ulcers for 1 of 1 sampled resident (#1) reviewed for pressure ulcers. This placed residents at r...
Read full inspector narrative →
Based on interview and record review it was determined the facility failed to assess and treat diabetic ulcers for 1 of 1 sampled resident (#1) reviewed for pressure ulcers. This placed residents at risk for worsening skin conditions. Findings include:
Resident 1 admitted to the facility in 2018 with diagnoses including stroke and diabetes.
A 4/1/23 progress note indicated Resident 1 had a wound on her/his right great toe, it was swollen and an open area was noted to be a 2 cm round wound.
Wound Care notes indicated the resident had a diabetic ulcer to the right great toe measuring as follows:
-4/5/23 0.70 cm x 1.0 cm.
Topical care: cleanse with wound cleanser; apply skin prep to peri-wound; primary dressing: therahoney to wound base; secondary dressing: 2 x 2 Allevyn (foam dressing); change every week and PRN if it falls off.
-4/12/23 0.80 cm x 0.80 cm [no changes to treatment].
-4/19/23 0.50 cm x 0.50 cm [no changes to treatment]. Plan to schedule to return in one month.
There was no indication the wound care orders from the 4/5/23 wound consult were implemented.
Resident 1's physician orders signed on 4/6/23 and 5/4/23 indicated to place Allevyn on the right great toe and change every day at bedtime and PRN for protection.
The 4/2023 TARs indicated:
-Place Allevyn on the right great toe. Change once daily at bedtime to protect right great toe.
Change every day, and as needed PRN. (order date 4/4/23 and discontinued on 4/17/23).
The 5/2023 TARs indicated the following treatment started on 5/4/23:
Wound care, leave area of right great toe pressure ulcer open to air during the day, cover only with non-skid sock, no shoe one time a day.
There was no indication additional wound measurements were completed for the right great toe from 4/19/23 until 5/4/23 (15 days later) and the wound measured 0.1 cm x 0.1 cm. Subsequent measuring was not completed again until 5/16/23 (12 days later) and the wound measured 0.1 cm x 0.1 cm.
On 5/17/23 at 10:46 AM Staff 9 (RN) stated normally the wound care nurse came weekly and completed assessments including measuring and treatment recommendations.
On 5/17/23 at 1:08 PM and 1:23 PM Staff 2 (DNS) acknowledged there was a discrepancy with the documentation which indicated a pressure ulcer versus a diabetic ulcer and wound assessments and measurements were not completed timely. Staff 2 acknowledged the wound care orders were not implemented and the physician orders did not reflect the wound care orders. Staff 2 stated there was a delay in getting signed orders from the physician. Staff 2 further stated the wound care nurse completed weekly wound assessments until 4/19/23 and there were no additional measurements completed until 5/4/23 and then subsequent measuring was not completed until 5/16/23.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to assess and treat pressure ulcers for 1 of 1 sampled resident (#1) reviewed for pressure ulcers. This placed residents at r...
Read full inspector narrative →
Based on interview and record review it was determined the facility failed to assess and treat pressure ulcers for 1 of 1 sampled resident (#1) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include:
Resident 1 admitted to the facility in 2018 with diagnoses including stroke.
A 3/29/23 progress note indicated Resident 1 had a 1.4 cm x 0.8 cm x 0.3 cm wound to the left gluteal fold. The area was cleansed with wound cleanser and gauze, and covered with dressing.
Wound Care notes indicated the Stage 3 pressure area to the left buttock was assessed and measured as follows:
*4/5/23 0.9 cm x 1.5 cm x 0.1 cm.
Topical care: cleanse with wound cleanser; apply skin prep to peri-wound; primary dressing: therahoney to wound base; secondary dressing 2 x 2 Allevyn. Change twice weekly and PRN if soiled or falls off.
*4/12/23 0.9 cm x 1.5 cm x 0.1 cm (no changes to treatment).
*4/19/23 0.9 cm x 1.5 cm x 0.1 cm (no changes to treatment). Plan to schedule to return in one month.
The 4/6/23 and 5/4/23 physician orders indicated Allevyn dressing to left gluteal fold one time a day for Stage 2 wound to right gluteal fold until healed.
The 4/2023 and 5/2023 TARs indicated Resident 1 was to receive the following treatment:
a. Allevyn dressing to left gluteal fold one time a day for Stage 2 wound to right gluteal fold. Place until healed.
-The TARs indicated this was completed from 4/1/23 through 4/30/23 except for dressing changes on 4/22/23 and 4/26/23 were not documented as completed.
b. Left buttock: Cleanse with wound cleanser; apply skin prep to peri-wound; Primary dressing: therahoney to wound base; Secondary dressing 2 x 2 Allevyn; change 2 x/week and PRN if soiled or falls off one time a day every Tuesday, Thursday for pressure ulcer.
-The TARs indicated this was to start on 4/11/23. There was no indication wound care was completed on 4/11/23; 4/13/23; 4/18/23; 4/20/23; 4/25/23; 4/27/23; 5/2/23; 5/4/23; 5/9/23 and 5/11/23.
There was no indication additional wound measurements were completed for the left buttock wound from 4/19/23 until 5/4/23 (15 days later) and the wound measured 0.9 cm x 1.5 cm x 0.1 cm. Subsequent measuring was not completed again until 5/16/23 (12 days later) and the wound measured 1 cm x 1.4 cm x 0.2 cm.
On 5/17/23 at 10:46 AM Staff 9 (RN) stated normally the wound care nurse came weekly and completed assessments including measuring and treatment recommendations.
On 5/17/23 at 1:08 PM and 1:23 PM Staff 2 (DNS) acknowledged Resident 1 had one pressure ulcer to the left buttock and there was a discrepancy with the staging of the pressure ulcer from a Stage 2 versus a Stage 3. Staff 2 acknowledged wound assessments and measurements were not completed timely. Staff 2 acknowledged the wound care orders were not implemented and the and the physician orders did not reflect the wound care orders. Staff 2 further acknowledged the 4/2023 and 5/2023 TARs indicated the identified dressing changes were missed. Staff 2 stated there was a delay in getting signed orders from the physician and the wound care nurse completed weekly wound assessments until 4/19/23 and there were no additional measurements completed until 5/4/23 and then subsequent measuring was not completed until 5/16/23.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to have an order in place for the use of...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to have an order in place for the use of a catheter for 1 of 2 sampled residents (#119) reviewed for catheters. This placed residents at risk for urinary tract infections. Findings include:
Resident 119 admitted to the facility on [DATE] with diagnoses including failure to thrive.
The 4/19/23 admission Summary indicated Resident 119 had a Foley catheter when she/he admitted to the facility.
No initial physician order for the catheter was located in Resident 119's clinical record.
Resident 119's 4/24/23 hospice orders indicated the following:
-Foley catheter to down drain; replace every six weeks or by order. May irrigate with 60 cc normal saline PRN.
The 4/2023 and 5/2023 TARs did not indicate orders to irrigate the catheter and did not include monitoring of the catheter.
On 5/15/23 at 9:11 AM, 12:53 PM and 2:23 PM Resident 119's catheter bag and tubing were observed to be hanging on the bed.
A review of the clinical record on 5/16/23 indicated no current physician order for the Foley catheter.
On 5/16/23 at 1:00 PM and 2:04 PM Staff 1 (Administrator) acknowledged Resident 119 did not have a current physician order for the Foley catheter.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 2 was admitted to the facility in 2015 with diagnoses including diabetes and cellulitis.
A 10/11/19 physician order...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 2 was admitted to the facility in 2015 with diagnoses including diabetes and cellulitis.
A 10/11/19 physician order indicated Resident 2 was to receive penicillin two times a day for cellulitis. The order did not have an end date
On 5/16/23 at 11:30 AM Staff 9 (RN) stated Resident 2 was on penicillin prophylactically.
On 5/16/23 the state survey team requested a rationale for the use of penicillin was made. A log note from the physician was received patient had at least four hospitalizations for recurrent panniculitis. I consulted infectious disease at OHSU [Oregon Health Science University] and they recommended she be placed on PCN [penicillin] to prevent recurrence. It has been helpful.
A 12-month review of the pharmacist recommendation/review did not indicate review of Resident's prolonged antibiotic use.
On 5/17/23 at 12:28 PM Staff 8 (Pharmacist) stated it did not sound right that a resident was on an antibiotic for four years without her catching it. Staff 8 stated she sometimes did medication reviews in person or over the phone and did not know the start dates of the resident medications that she reviewed monthly.
On 5/17/23 at 2:40 PM Staff 1 (Administrator) acknowledged the monthly pharmacy reviews were not thorough.
Based on interview and record review it was determined the facility failed to ensure a thorough medication regimen review was completed by the pharmacist monthly for 2 of 2 sampled residents (#s 2 and 4) reviewed for antibiotic use. This placed residents at risk for adverse medication side effects. Findings include:
1. Resident 4 admitted to the facility on [DATE] with diagnoses including multiple sclerosis.
The 3/2/23 physician orders indicated Resident 4 received cephalexin 500 mg once daily for UTI prophylaxis. The order indicated the initial start date was 5/25/22.
A review of the resident's clinical record revealed no evidence the resident's use of cephalexin was reviewed by a pharmacist.
On 5/16/23 the state survey team requested a rationale for Resident 4's use of cephalexin. A log note from the physician was received that indicated appears [she/he] is on daily Keflex [cephalexin] for UTI prophylaxis given [her/his] frequent UTIs previously.
On 5/17/23 at 12:28 PM Staff 8 (Pharmacist) stated she looked for supporting diagnoses for the medications and was not aware that Resident 4 received cephalexin from 5/25/22 to current (5/17/23) and did not know the start dates of resident medications that she reviewed monthly.
On 5/17/23 at 2:47 PM Staff 1 (Administrator) acknowledged the monthly pharmacy reviews were not thorough.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
2. Resident 2 was admitted to the facility in 2015 with diagnoses including diabetes and depression.
A 5/15/23 Care Plan indicated Resident 2 used antidepressant medication related to the diagnoses of...
Read full inspector narrative →
2. Resident 2 was admitted to the facility in 2015 with diagnoses including diabetes and depression.
A 5/15/23 Care Plan indicated Resident 2 used antidepressant medication related to the diagnoses of depression. Interventions included to monitor side effects and effectiveness of the medication.
Review of the provided February, March, April and May 2023 psychotropic reviews entitled Pharmacist Recommendations/Review indicated a 30-day review was completed and with no recommendations. No other documentation related to a psychotropic drug review were indicated. The form included signatures of the pharmacist and the physician only.
At 5/16/23 at 10:16 AM Staff 9 (RN) confirmed that facility did not complete psychotropic meetings for any residents.
On 5/16/23 at 10:16 AM and 5/17/23 at 11:16 AM Staff 1 (Administrator) stated the facility did not complete psychotropic drug meetings for any residents including Resident 2.
Based on interview and record review it was determined the facility failed to complete psychotropic drug reviews for 2 of 5 sampled residents (#s 2 and 8) reviewed for medications. This place residents at risk for unnecessary medications. Findings include:
1. Resident 8 admitted to the facility in 2021 with diagnoses including chronic pain, dysthymic disorder and epilepsy.
The 4/8/21 Care Plan indicated Resident 8 used antidepressant medication related to the diagnoses of dysthymic disorder. Interventions included to monitor side effects and effectiveness of the medication.
Review of the provided February, March and April 2023 psychotropic reviews entitled Pharmacist Recommendations/Review indicated a 30 day review was completed with no recommendations. No other documentation related to a psychotropic drug review were indicated. The form included signatures of the pharmacist and the physician only.
On 5/16/23 at 10:16 AM and 5/17/23 at 11:16 AM Staff 1 (Administrator) stated the facility did not complete psychotropic drug meetings for any residents including Resident 8.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to ensure medical records were complete and accurate for 1 of 6 sampled residents (#8) reviewed for medications. This placed ...
Read full inspector narrative →
Based on interview and record review it was determined the facility failed to ensure medical records were complete and accurate for 1 of 6 sampled residents (#8) reviewed for medications. This placed residents at risk for incomplete medical records. Findings include:
Resident 8 admitted to the facility in 2021 with diagnoses including chronic pain, dysthymic disorder and epilepsy.
7/13/22 physician orders indicated CMP (comprehensive metabolic panel) and CBC (complete blood count) labs were to be completed annually (February) and the dilantin level (tests level of dilantin [seizure medication] in the blood) every 6 months (February and August). The orders indicated Resident 8 received 100 mg of phenytion (dilantin) BID related to seizures.
A progress note dated 2/8/23 indicated Resident 8's blood was drawn for CMP, CBC and dilantin level and sent to the lab.
Review of Resident 8's medical record revealed results for from the CBC lab and no documentation of the results for the CMP or dilantin labs were found.
On 5/17/23 at 11:03 AM Staff 1 (Administrator) acknowledged the lab results for the CMP and dilantin level were not in Resident 8's medical record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation and interview it was determined the facility failed to ensure proper placement of a resident's catheter to prevent infection for 2 of 2 sampled residents (#s 4 and 119) randomly o...
Read full inspector narrative →
Based on observation and interview it was determined the facility failed to ensure proper placement of a resident's catheter to prevent infection for 2 of 2 sampled residents (#s 4 and 119) randomly observed for infection control. This placed residents at risk for infection. Findings include:
1. Resident 4 admitted to the facility in 5/2022 with diagnoses including multiple sclerosis.
On 5/15/23 at 10:35 AM Resident 4's catheter bag and tubing were observed uncovered hanging on the bed with the lower part of the bag lying on the floor next to the resident's bed.
On 5/15/23 at 2:18 PM Resident 4's catheter bag was observed uncovered hanging on the recliner with the lower part of the bag touching the floor.
On 5/15/23 at 2:29 PM Staff 2 (DNS) confirmed Resident 4's catheter bag was touching the floor and expected it to be off the floor for infection control.
2. Resident 119 admitted to the facility in 2023 with diagnoses including failure to thrive.
On 5/15/23 at 9:11 AM, 12:53 PM and 2:23 PM Resident 119's catheter bag and tubing were observed uncovered hanging on the bed with the lower part of the bag lying on the floor next to the resident's bed.
On 5/15/23 at 2:29 PM Staff 2 (DNS) confirmed Resident 119's catheter bag was touching the floor and expected it to be off the floor for infection control.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected multiple residents
Based on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 2 of 2 sampled CNA staff (#s 5 and 6) reviewed for staffing...
Read full inspector narrative →
Based on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 2 of 2 sampled CNA staff (#s 5 and 6) reviewed for staffing. This placed residents at risk for a lack of competent staff. Findings include:
On 5/16/23 at 10:18 AM Staff 1 (Administrator) was asked for the annual performance reviews for Staff 5 (CNA) and Staff 6 (CNA).
Employee performance reviews indicated the following:
-Staff 5 was hired 3/1995 and the last performance review was completed in 2021;
-Staff 6 was hired 7/2020 and the last performance review was completed in 2021.
On 5/16/23 at 2:31 PM Staff 1 acknowledged the last performance review for Staff 5 and Staff 6 was completed in 2021 and the annual performance reviews were not completed for 2022 for the identified CNA staff.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected multiple residents
Based on interview and record review it was determined the facility failed to implement an antibiotic stewardship program for 1 of 1 facility reviewed for antibiotic stewardship. This placed residents...
Read full inspector narrative →
Based on interview and record review it was determined the facility failed to implement an antibiotic stewardship program for 1 of 1 facility reviewed for antibiotic stewardship. This placed residents at risk for developing antibiotic resistance. Findings include:
On 5/17/23 at 9:52 AM a request was made for the antibiotic stewardship program documentation from Staff 2 (DNS/IP).
On 5/17/23 at 9:52 AM Staff 2 stated the facility had no process to track antibiotic use and did not have an antibiotic stewardship program in place.
Apr 2022
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to ensure the resident was free from unnecessary medi...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to ensure the resident was free from unnecessary medication for 1 of 5 sampled residents (#2) reviewed for medications. This placed residents at risk for adverse side effects of medications. Findings include:
Resident 2 was readmitted to the facility on [DATE] with diagnoses including diabetes.
The 4/18/22 physician order indicated Resident 2 was to receive Metformin (antidiabetic medication) 1000 mg BID.
The 4/21/22 physician orders did not include Metformin 1000 mg BID.
The 4/2022 MARs were reviewed on 4/26/22. The MARS indicated Resident 2 received Metformin 1000 mg BID for diabetes from 4/18/22 through the morning of 4/26/22.
On 4/27/22 at 1:30 PM Staff 2 (DNS) stated the nurse that took the orders on 4/21/22 did not update the MAR appropriately and removing the Metformin from the MAR was missed. Staff 2 further stated the MAR should have been updated to reflect the current orders.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to ensure psychotropic assessments were completed, gradual dose reductions were attempted unless clinically contraindicated, ...
Read full inspector narrative →
Based on interview and record review it was determined the facility failed to ensure psychotropic assessments were completed, gradual dose reductions were attempted unless clinically contraindicated, and residents were aware of risk versus benefits of psychotropic medications for 2 of 5 sampled residents (#s 1 and 2) reviewed for medications. This placed residents at risk for unnecessary medications and adverse side effects. Findings include:
1. Resident 1 admitted to the facility in 10/2018 with diagnoses including insomnia and major depressive disorder.
a. The 10/27/18 physician order indicated Resident 1 was to receive desvenlafaxine (antidepressant) daily.
The 4/2022 MAR indicated Resident 1 received desvenlafaxine daily.
Resident 1's medical record did not indicate a gradual dose reduction (GDR) for desvenlafaxine was attempted or evidence to indicate a GDR was contraindicated.
On 4/28/22 at 10:38 AM Staff 2 (DNS) stated a GDR was not completed and there was no clinical rationale to continue Resident 1's desvenlafaxine at the current dose.
b. The 3/8/22 physician order indicated Resident 1 was to receive mirtazapine (antidepressant) for insomnia related to depression daily.
The 4/2022 MAR indicated Resident 1 received mirtazapine daily.
Resident 1's medical record did not indicate the resident had signed a consent for risk versus benefits related to mirtazapine.
On 4/28/22 at 10:38 AM and 4/29/22 at 9:41 AM Staff 2 (DNS) stated Resident 1 did not have a signed consent form for risk versus benefits for mirtazapine. Staff 2 further stated she was unable to locate psychotropric drug reviews for the past 90 days.
2. Resident 2 admitted to the facility in 2015 with diagnoses including adjustment disorder with depressed mood.
The 4/2022 MAR indicated Resident 2 received Celexa (antidepressant) once daily for depression.
A review of the clinical record revealed there was no GDR attempted and no clinical rationale as to why a GDR should not be completed.
On 4/29/22 at 9:30 AM Staff 8 (RN) stated Resident 2 occasionally got teary but was usually in a really good mood.
On 4/29/22 at 9:38 AM Staff 9 (CNA) stated Resident 2 occasionally got upset after talking on the phone but did not seem to be depressed.
On 4/29/22 at 9:41 AM Staff 2 (DNS) acknowledged a GDR had not been attempted for Resident 2's Celexa and there was no clinical rationale as to why a GDR had not been attempted. Staff 2 further stated she was unable to locate psychotropric drug reviews for the past 90 days.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0825
(Tag F0825)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review it was determined the facility failed to obtain therapy services for 1 of 1 sampled resident (#1) reviewed for therapy services. This placed residents...
Read full inspector narrative →
Based on observation, interview and record review it was determined the facility failed to obtain therapy services for 1 of 1 sampled resident (#1) reviewed for therapy services. This placed residents at risk for a decline in functional abilities and accidents. Findings include:
1. Resident 1 admitted to the facility in 10/2018 with diagnoses including cerebral palsy.
A 10/26/18 Dietary Order indicated Resident 1 had a regular diet with TAT (texture as tolerated).
The 1/30/22 Quarterly MDS indicated Resident 1 was alert and oriented (BIMS 15) and had no issues swallowing.
A 3/15/22 RD assessment indicated noted swallowing concerns and recommended a speech therapy evaluation with Small bites and sips recommended by OT [Occupational Therapist]. The resident was noted as independent with eating.
A 3/17/22 Nurses Note indicated the RD recommended a speech assessment due to reported difficulty swallowing. The recommendation was faxed to the physician and was signed in agreement. The nurse on duty called home health for the speech therapist to evaluate but reported they had no one to complete the assessment as their speech therapist went out on maternity leave and would not be returning. The nurse on duty then called the hospital therapy department to see if they had anyone to perform the assessment and reported they do not go outside the hospital. The information was reported to the DNS, and she was looking into other sources to get the assessment completed and to continue to monitor the resident for changes.
Resident 1's medical record did not indicate a speech evaluation was completed prior to 4/28/22.
Observations of Resident 1 during meals from 4/26/22 through 4/28/22 did not reveal any concerns with swallowing.
On 4/28/22 at 3:03 PM Resident 1 stated she/he had no concerns with eating or swallowing and had not had any choking episodes.
On 4/28/22 at 10:41 AM Staff 2 (DNS) acknowledged the 3/17/22 RD recommendation and confirmed Resident 1 had not yet been assessed by speech therapy.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected multiple residents
Based on interview and record review it was determined the facility failed to ensure identified risks were comprehensively assessed to determine underlying causes and the impact on the resident for 4 ...
Read full inspector narrative →
Based on interview and record review it was determined the facility failed to ensure identified risks were comprehensively assessed to determine underlying causes and the impact on the resident for 4 of 9 sampled residents (#s 1, 3, 7, and 13) reviewed for falls, psychotropic drug use, nutrition, unnecessary medications, and dementia. This placed residents at risk for unassessed care needs. Findings include:
1. Resident 1 admitted to the facility in 10/2018 with diagnoses including cerebral palsy, a history of falls, and major depressive disorder.
Resident 1 had a 10/27/18 physician order for desvenlafaxine (antidepressant) and mirtazapine (antidepressant) for insomnia related to depression.
The 1/30/22 Annual MDS Falls and Psychotropic CAAs were triggered. Both CAAs were left blank.
On 4/27/22 at 2:29 PM Staff 2 (DNS) confirmed Resident 1's Fall and Psychotropic CAAs were not comprehensive.
2. Resident 13 admitted to the facility in 2021 with diagnoses including dementia.
The 2/6/22 Annual Cognitive Loss/Dementia CAA indicated Resident 13 had cognitive loss related to dementia as evidenced by a BIMS score of zero. No further information was provided to indicate the resident's history related to her/his dementia, medications used to treat the diagnoses, any behaviors noted or interventions in place related to the resident's dementia.
On 4/29/22 at 9:41 AM Staff 2 (DNS) acknowledged Resident 2's Cognitive Loss/Dementia CAA was not comprehensive.
3. Resident 3 admitted to the facility in 2022 with diagnoses including Alzheimer's disease and diabetes.
The 2/9/22 admission Dementia CAA indicated the resident had dementia with impaired decision. No further information was provided to indicate the resident's history related to her/his dementia, medications used to treat the diagnoses, any behaviors noted or interventions in place related to the resident's dementia.
The 2/9/22 admission Psychotropic Medication Use CAA indicated the resident had depression medications related to chronic depression, no further information was provided. The CAA did not indicate the resident's history of depression, medication used and any behaviors exhibited or interventions in place.
On 4/27/22 at 2:22 PM Staff 2 (DNS) confirmed Resident 3's Dementia and Psychotropic Medication Use CAA were not comprehensive.
4. Resident 7 admitted to the facility in 2020 with diagnoses including diabetes and obesity.
The 1/24/22 admission Nutrition CAA indicated the resident had an elevated Body Mass Index (BMI)and was on a therapeutic diet. The CAA did not indicate of the resident history related to her/his nutrition, indications of why the resident was a risk for nutritional concerns or referred to the indication for the therapeutic diet.
On 4/27/22 at 2:22 PM Staff 2 (DNS) confirmed Resident 7's nutritional CAA was not comprehensive.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to ensure the facility maintained a medi...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to ensure the facility maintained a medication error rate of less than 5%. There were six errors in 31 opportunities resulting in a 19% medication error rate. This placed residents at risk for adverse side effects from medications. Findings include:
1. Resident 14 admitted to the facility in 2021 with diagnoses including post traumatic seizures and history of traumatic brain injury.
The 4/12/22 physician order indicated Resident 14 was to receive the following:
-valproic acid 250 mg/5 ml give 20 ml PO BID for seizure disorder;
-lamotrigine 100 mg 1 tab PO BID for seizure from traumatic brain injury;
-docusate sodium 100 mg BID for constipation.
On 4/27/22 at 8:55 AM Staff 3 (LPN) was observed to administer valproic acid 250 mg/5 ml 20 ml and lamotrigine 100 mg 1 tab. Staff 3 acknowledged the medications were used for seizure prevention, the medications were due at 7 AM and were administered one hour and 55 minutes late. Staff 3 was not observed to administer docusate sodium 100 mg. Staff 3 the docusate sodium was not administered due to the medication being unavailable.
On 4/27/22 at 1:54 PM Staff 2 (DNS) acknowledged docusate sodium was not available during the medication pass on the morning of 4/27/22. Staff 2 stated Resident 14 received valproic acid and lamotrigine for the prevention of seizures, the expectation was for the medications to be administered on time, and acknowledged the resident received the medications one hour and 55 minutes after they were due. Staff 2 acknowledged the facility did not have the correct dose of docusate sodium in stock and the resident did not receive it.
2. Resident 8 admitted to the facility in with diagnoses including glaucoma.
The 4/12/22 physician order indicated Resident 8 was to receive the following:
-Timoptic Solution 0.5% instill one drop in both eyes BID for glaucoma;
-brimonidine tartrate solution 0.2% instill one drop in both eyes BID for glaucoma.
The 2022 Nursing Drug Handbook indicated if more than one opthalmic medication (eye medication) was administered to give the medications at least five minutes apart.
On 4/27/22 at 8:21 AM Staff 3 (LPN) was observed to administer the following medications to Resident 8:
-Timoptic Solution one drop in each eye;
-brimonidine tartrate solution one drop in each eye;
-Staff 3 did not waiting five minutes in between the administration between each eye drops.
On 4/27/22 at 1:01 PM Staff 3 reviewed the Nursing Drug Handbook and acknowledged the Timoptic Solution and brimonidine tartrate solution were administered to Resident 8 without waiting the recommended five minutes in between eye drop administrations.
On 4/27/22 at 1:54 PM Staff 2 (DNS) acknowledged staff were expected to wait five minutes in between administering doses of opthalmic medication.
3. Resident 3 admitted to the facility on [DATE] with diagnoses including diabetes.
The 2/3/22 physician order indicated Resident 3 was to receive Vitamin D3 50 mcg two tablets PO QD for supplement.
On 4/27/22 at 7:26 AM Staff 3 (LPN) was observed to administer Vitamin D3 50 mcg one tablet to Resident 3.
On 4/27/22 at 8:30 AM Staff 3 was asked about the orders and administration of Vitamin D3. Staff 3 acknowledged the resident received one tablet of Vitamin D3 50 mcg instead of the ordered two tablets.
On 4/27/22 at 1:54 PM Staff 2 (DNS) acknowledged Resident 3 received Vitamin D3 50 mcg one tablet instead of the ordered two tablets and the expectation was for the residents to receive medications as ordered.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected multiple residents
Based on interview and record review it was determined the facility failed to develop and implement an antibiotic stewardship program (ASP) that included feedback to prescribing providers on their ant...
Read full inspector narrative →
Based on interview and record review it was determined the facility failed to develop and implement an antibiotic stewardship program (ASP) that included feedback to prescribing providers on their antibiotic use, review of antibiotic resistance patterns based on laboratory data (Antibiogram) specific for facility infections and follow-up surveillance to ensure treated infections met antibiotic use protocols (AUP) and represented the treatment of true infections versus colonization. These failures increased residents' risk for multidrug-resistant organisms (MRDO), Clostridioides Difficile (a bacterium that causes severe diarrhea) and adverse drug events for 1 of 1 facility. Findings include:
The CDC Core Elements of Antibiotic Stewardship https://www.cdc.gov/antibiotic-use/core-elements/nursing-homes.html, dated 8/2021 indicated Antibiotics are among the most frequently prescribed medications in nursing homes, with up to 70% of residents in a nursing home receiving one or more courses of systemic antibiotics when followed over a year. Harms from antibiotic overuse are significant for the frail and older adults receiving care in nursing homes. These harms include risk of serious diarrheal infections from Clostridoides difficile, increased adverse drug events and drug interactions, and colonization and/or infection with antibiotic-resistant organisms. Core elements of a facility Antibiotic Stewardship Program should include analysis of infections and causative bacteria along with resistant data specific to both the facility and the type of infection (Antibiogram). This information should be given to the prescriber for appropriate antibiotic selection. Further retrospective infection surveillance utilizing McGeers Criteria should be conducted to ensure correct use of antibiotic therapy adherence to facility antibiotic use protocols (AUP) and the treatment of true infections versus colonization.
The facility's undated Antibiotic Stewardship Policy indicated the following:
- The facility shall balance the need for prompt first dose of antimicrobial therapy with the need to prevent antimicrobial overuse. The prescribing clinicians shall be encouraged to utilize the antibiotic time out as a component of the program. When the identified antimicrobial agents are ordered, the team shall, upon receiving notification of a restricted antimicrobial agent, review the case and provide recommendations to the prescribing physician.
On 4/28/22 at 1:49 PM Staff 2 (DNS), Staff 4 (RNCM) and Staff 5 (RN) were interviewed regarding the facility's antibiotic stewardship. Staff 4 stated a map of resident rooms was color coded which indicated an infection was present and an antibiotic was used. Staff 4 stated tracking was completed monthly. Staff 4 stated the facility had no history of using McGeers criteria or any other clinical decision making process. Staff 2 stated they were waiting for contract approval for a infection control module and point of care to be able to implement McGeers. Staff 2 confirmed the facility had not been implementing any antibiotic stewardship. Staff 2 also further confirmed the facility was also not currently implementing any culture and sensitivity prior to prescribing an antibiotic and further education was required for the medical provider and pharmacy.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0888
(Tag F0888)
Could have caused harm · This affected multiple residents
Based on interview and record review it was determined the facility failed to have access to documented COVID-19 status for all staff and access to documented staff who had requested or had been grant...
Read full inspector narrative →
Based on interview and record review it was determined the facility failed to have access to documented COVID-19 status for all staff and access to documented staff who had requested or had been granted an exemption for the COVID-19 vaccination. This placed residents at increased risk for exposure to COVID-19. Findings include:
On 4/26/22 the facility provided documentation that indicated Witness 2 (Employee Health Nurse at local hospital) was to be contacted related to the staff vaccination report.
On 4/26/22 at 11:00 AM Staff 2 (DNS) indicated the human resources department at the hospital would not release the employee vaccination status for facility staff to them due to privacy reasons and requested the report be directed emailed to the surveyor. Staff 2 stated the facility currently had no knowledge of the vaccination status for all facility staff employees.
On 4/26/22 at 2:45 PM an email was received from Witness 2 regarding the vaccination status for all facility staff.
On 4/28/22 at 8:54 AM Witness 2 was contacted to obtain further information related to staff exemptions. Witness 2 stated she did not have the information and the information would have to be obtained from Witness 3 (Human Resources Director).
On 4/28/22 at 9:12 AM Witness 3 provided the COVID-19 vaccination exemption status for the requested facility staff.
On 4/28/22 at 10:31 AM Staff 1 (Administrator) and Staff 2 confirmed they did have access to facility staff vaccination status.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0713
(Tag F0713)
Could have caused harm · This affected most or all residents
Based on interview and record review it was determined the facility failed to have a process in place to address concerns with the residents' attending physician who also functioned as the medical dir...
Read full inspector narrative →
Based on interview and record review it was determined the facility failed to have a process in place to address concerns with the residents' attending physician who also functioned as the medical director to ensure medical care was provided according to clinical standards and regulatory requirements. This placed residents at risk for untimely medical care. Findings include:
The 3/1/21 Physician Services Policy indicated:
(d) Availability of physicians for emergency care. The facility must provide or arrange for the provision of physician services 24 hours a day, in case of emergency.
On 4/28/22 at 10:40 AM Staff 5 (RN) stated when the medical director was working during clinic hours they could reach her by phone at the clinic but otherwise staff always had to go through the emergency department if there was an emergency. Staff 5 stated if the medical director was on vacation staff were also expected to call the emergency department if a resident had a change of condition or had questions for the physician. Staff 5 stated there were occasions when she had contacted the emergency department and the physician was busy and unavailable to take a call right away. Staff 5 stated she waited never more than an hour for the emergency department physician to respond. Staff 5 stated if the emergency department physician was unavailable they spoke to emergency room nursing staff. Staff 5 stated the medical director was currently on vacation.
On 4/28/22 at 1:10 PM Staff 3 (LPN) stated she was unaware of who the medical director was or how to contact them. Staff 3 stated the process was to contact Staff 2 (DNS) if a resident needed to be sent to the hospital or there were questions regarding a change of condition. Staff 3 stated she called the emergency department and talked to the medical assistant or nurse regarding the resident if she had a concern. Staff 3 stated after a resident was sent to the hospital she then faxed the physician of the rationale for sending the resident to the hospital.
On 4/28/22 at 4:44 PM Staff 10 (LPN) stated if a resident had a change in condition she wrote an FYI [for your information] to the doctor and faxed it. Staff 10 further stated if a resident had a non-emergency situation she called the emergency department physician to get orders and notified Staff 2 (DNS). Staff 10 stated she faxed the physician or medical director at the clinic the rationale for sending the resident to the hospital.
On 4/28/22 at 1:14 PM Staff 2 (DNS) stated currently staff were unable to contact the medical director 24 hours a day seven days a week. Staff 2 stated staff could call the hospital emergency department, herself or Staff 5 (RN) for further direction if an emergency arose. Staff 2 further stated there was no process to ensure the medical director or designee was available to be contacted by phone on a 24 hour basis.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to ensure a pharmacist conducted a medication regimen...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to ensure a pharmacist conducted a medication regimen review at least monthly for 5 of 5 sampled residents (#s 1, 2, 3, 11 and 13) review for medications. This placed residents at risk for adverse side effects and unnecessary medications. Findings include:
1. Resident 1 admitted to the facility in 10/2018 with diagnoses including cerebral palsy and major depressive disorder.
A review of Resident 1's medical record did not reveal monthly pharmacy reviews were completed.
The 4/2022 MAR indicated Resident 1 received several medications including an anticoagulant and two antidepressants.
On 4/26/22 Resident 1's monthly medication pharmacy reviews were requested for the last three months.
On 4/27/22 at 3:18 PM Staff 2 (DNS) stated there were no pharmacy reviews for the past three months for Resident 1 and there was no current process for the pharmacist to perform monthly medication regimen reviews for residents.
2. Resident 11 admitted to the facility in 7/2018 with diagnoses including a pelvic fracture and stroke.
A review of Resident 11's medical record did not reveal monthly pharmacy reviews were completed.
The 4/2022 MAR indicated Resident 11 received several medications including an antidepressant.
On 4/26/22 Resident 11's monthly medication pharmacy reviews were requested for the last three months.
On 4/27/22 at 3:18 PM Staff 2 (DNS) stated there were no pharmacy reviews for the past three months for Resident 11 and there was no current process for the pharmacist to perform monthly medication regimen reviews for residents.
3. Resident 2 admitted to the facility in 2015 with diagnoses including heart failure.
The 4/2022 MAR indicated Resident 2 received several medications including an antidepressant.
On 4/26/22 Resident 2's monthly medication pharmacy reviews were requested for the last three months.
On 4/27/22 at 3:18 PM Staff 2 (DNS) stated there were no pharmacy reviews for the past three months for Resident 2 and there was no current process for the pharmacist to perform monthly medication regimen reviews for residents.
4. Resident 13 admitted to the facility in 2021 with diagnoses including dementia.
The 4/2022 MAR indicated Resident 13 received several medications including an antipsychotic and an antidepressant.
On 4/26/22 Resident 13's monthly medication pharmacy reviews were requested for the last three months.
On 4/27/22 at 3:18 PM Staff 2 (DNS) stated there were no pharmacy reviews for the past three months for Resident 13 and there was no current process for the pharmacist to perform monthly medication regimen reviews for residents.
5. Resident 3 admitted to the facility on [DATE] with diagnoses including Alzheimer's, diabetes, pain and hypertension.
Review of Resident's 3 medical record revealed on indication a pharmacy review was completed since admission.
The 4/2022 MAR indicated Resident 3 received multiple medications including an antipsychotic.
On 4/26/22 Resident 3's monthly medication pharmacy reviews were requested for the last three months.
On 4/27/22 at 3:18 PM Staff 2 (DNS) stated there were no pharmacy reviews for the past three months for Resident 3 and there was no current process for the pharmacist to perform monthly medication regimen reviews for residents.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Oregon facilities.
Concerns
- • 28 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade C (50/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 50/100. Visit in person and ask pointed questions.
✓ Report will be sent to your email
About This Facility
What is Blue Mountain's CMS Rating?
CMS assigns BLUE MOUNTAIN CARE CENTER an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Oregon, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Blue Mountain Staffed?
CMS rates BLUE MOUNTAIN CARE CENTER's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes.
What Have Inspectors Found at Blue Mountain?
State health inspectors documented 28 deficiencies at BLUE MOUNTAIN CARE CENTER during 2022 to 2024. These included: 28 with potential for harm.
Who Owns and Operates Blue Mountain?
BLUE MOUNTAIN CARE CENTER is owned by a government entity. Government-operated facilities are typically run by state, county, or municipal agencies. The facility operates independently rather than as part of a larger chain. With 40 certified beds and approximately 14 residents (about 35% occupancy), it is a smaller facility located in PRAIRIE CITY, Oregon.
How Does Blue Mountain Compare to Other Oregon Nursing Homes?
Compared to the 100 nursing homes in Oregon, BLUE MOUNTAIN CARE CENTER's overall rating (2 stars) is below the state average of 3.0 and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Blue Mountain?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is Blue Mountain Safe?
Based on CMS inspection data, BLUE MOUNTAIN CARE CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Oregon. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Blue Mountain Stick Around?
BLUE MOUNTAIN CARE CENTER has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.
Was Blue Mountain Ever Fined?
BLUE MOUNTAIN CARE CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Blue Mountain on Any Federal Watch List?
BLUE MOUNTAIN CARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.