Sarah Knutson couldn’t believe what she was hearing.
It was October, and Knutson’s 87-year-old mother, Karen, had been receiving specialized care for about a month at Corvallis Manor. Knutson had already filed one complaint with state regulators about what she perceived as deplorable conditions at the nursing home. Now she was on the phone to a state hotline to lodge a second complaint with Oregon’s Department of Human Services.
Knutson alleged that her mother had received inadequate medical attention and care over a period of weeks, putting her mother’s life at risk before she was transferred to the emergency department of a local hospital, where she received a blood transfusion.
Knutson wanted the state to investigate. But she said she was told there were 600 complaints ahead of hers.
Officials might be able to get an inspector on site, she said she was told, in nine or 10 months.
“That’s unacceptable,” she remembered responding.
This at a nursing home that already had received the lowest overall quality rating from federal regulators. And this at a nursing home that was one of only four in Oregon placed on a short list of candidates for a so-called Special Focus Facility designation to improve quality of care and receive more regular inspections because of a pattern of serious problems identified by regulators.
It was only after Knutson emailed her concerns to Gov. Tina Kotek’s office that the state fast-tracked an investigation, confirming the majority of problems outlined in her first complaint but not substantiating the more serious allegation in the second about her mother’s care.
Aside from elevating her concerns, Knutson’s experience is hardly unique. Like many of the facilities it is charged with regulating, Oregon’s Nursing Facility Survey Unit is understaffed and overburdened, delaying both its routine annual inspections and investigations of complaints. That, advocates say, puts residents in danger. Among the issues:
The number of complaint allegations filed about Oregon nursing homes in 2023 reached its highest point in at least five years while response times to investigate certain high-priority complaints have grown well beyond benchmarks set by state statute and the Centers for Medicare & Medicaid Services.The volume of pending complaints against nursing homes that have yet to be processed, and the number of underlying allegations in those complaints, ballooned during the pandemic and remains stubbornly high. As of mid-October, the number of complaints pending investigation had more than doubled since 2019 while the count of underlying allegations had more than quadrupled.The state is not meeting a federal requirement to perform a comprehensive evaluation of each of its 128 nursing homes once every 12.9 months, on average. Until December, a handful of nursing homes hadn’t received a comprehensive certification inspection in more than four years.Oregon doesn’t have enough inspectors. Because of turnover, long training periods and uncompetitive pay, the survey unit has been plagued by vacancy rates as high as one third of its budgeted number of surveyors, despite some increase in funding from the state to bolster staffing.Consumers haven’t been able to reliably look up old problems. Since August, technical problems on a state website prevented the public from consistently accessing information about past violations for nursing homes and other long-term care facilities. The agency initially said it wouldn’t be able to restore reliable access until spring or summer before saying that fixes appear to now be in place.
The Department of Human Services largely blames inspection delays on staffing shortages, compounded by the pandemic, which briefly shut down in-person assessments amid widespread COVID-19 outbreaks at the facilities.
“We take seriously the safety of residents and the importance of quality of care in our facilities,” said Corissa Neufeldt, deputy director of safety and regulatory oversight for the Department of Human Services’ Office of Aging and People with Disabilities. “This is a top priority. It’s a complex situation and we are taking active steps to try to improve our regulatory oversight, our practices and our staffing.”
Among those steps: Hiring an outside contractor with licensed surveyors to help work through the backlog of overdue investigations; twice-weekly safety huddles by division leaders to review incidents that resulted in serious injury or harm to residents; quarterly fatality reviews to identify breakdowns in the system; and in-person visits by agency leaders to long-term care facilities to get feedback directly from residents.
In the meantime, the agency has hired a consultant to evaluate the unit that licenses and regulates all long-term care providers, including nursing homes, to determine if the state has adequate staff and resources to ensure residents are safe and their needs are being met.
It’s a nationwide problem. A 2023 report by the U.S Senate Special Committee on Aging, “Uninspected and Neglected,” found that nursing facility survey units across the country were being stretched to the breaking point. The report said nearly a third of the nation’s 15,000 nursing homes were behind in comprehensive annual inspections and one in nine hadn’t received an inspection in two years or more.
Even so, federal regulators largely have given Oregon and other states passing marks on oversight metrics aimed at cutting the backlog. In the latest evaluation, issued in August, Oregon met the standards for nursing homes, including a 25% reduction in the numbers of complaints overdue for investigation; a 50% reduction in the number of past due recertification surveys; and undertaking at least 80% of complaint investigations that pose the most serious “immediate jeopardy” risks to residents within the required timeframe.
Richard Mollot, executive director of the Long Term Care Community Coalition, a New York-based advocacy organization, said federal regulators do a poor job of holding states accountable, consistently lowering the bar, and states’ poor oversight and enforcement means facilities rarely face any form of penalty except in the most egregious cases of neglect.
“It’s a cascade of weaknesses, a domino effect of failures,” he said. “And that’s why nursing home care is so crappy in this country.”
Fred Steele, Oregon’s long-term care ombudsman, said there are plenty of alarming complaints that take six to nine months for the state to investigate, by which time residents have moved, staffing has changed and any alleged neglect may be ongoing. He questioned the criteria the unit uses to prioritize complaints like Knutson’s and the resulting response times.
“They’re letting evidence go cold,” he said. “It’s a systemic problem. It’s much less safe given the regulatory environment nationally and in Oregon.”
Thousands of complaints
Oregon’s survey unit receives thousands of complaint allegations each year from nursing home residents, their relatives and the nursing facilities themselves when they self-report a problem. The number of allegations grew by more than 13% between 2019 and 2023, the most recent year with full data available, from 2,553 to 2,891, after temporarily declining during the pandemic.
Department data shows that 18% to 22% of allegations have been substantiated by investigators during the most recent five-year period and between 0.4% and 3.3% resulted in abuse or neglect findings.
State officials say they can’t pinpoint what’s driving the increase in complaints. But Neufeldt, the deputy director of safety and oversight, cited a variety of potential causes, including the increasingly complex medical needs of aging residents entering long-term care, the difficulty facilities face in maintaining a strong workforce amid a nationwide nursing shortage, and high turnover in facility ownership.
The congressional report laid the blame, in part, on less frequent annual inspections, which may compromise care and lead residents and families to file more complaints. Oregon officials agreed that could be a factor.
Federal policy requires nursing homes to undergo a comprehensive recertification inspection once every 12.9 months, on average, with a maximum interval between surveys of any facility not to exceed 15.9 months.
Like those in other states, Oregon’s inspection unit has had trouble meeting that benchmark. Its average survey interval is currently just over 14 months, more than a month beyond the federal mandate, according to the newsroom’s analysis of agency inspection data. And that’s an average calculated after federal officials let states exclude facilities where annual inspections were delayed because of pandemic restrictions. Without that reset, the average interval between the last two surveys was 20 months, and one in five nursing homes exceeded the maximum 15.9-month benchmark.
Last fall, there were seven nursing facilities in Oregon that hadn’t had a comprehensive survey in more than four years. Those were completed by year-end, agency officials said, adding that surveyors had been in all nursing homes multiple times during that period to monitor infection controls and staffing levels, or to investigate high priority complaints.
Oregon’s survey unit uses several factors to determine which facilities are prioritized for recertification and complaint surveys, including the number of pending allegations, the scope and severity of past violations and the facilities’ care and staffing ratings. A triage team evaluates and prioritizes complaints, and a surveyor goes on site to investigate, touring the facility, reviewing records and interviewing residents and staff.
State regulators document their findings and establish corrective action plans to address any identified failure to meet federal requirements that can impact residents’ health and safety. Violations can also lead to separate fines and other operation limits imposed by state and federal regulators, including a facility’s ability to accept new patients, a temporary denial of payments, or even termination from the Medicare and Medicaid programs that often pay for patient care.
Complaints about nursing homes run the gamut. Many are similar to Knutson’s complaints alleging that Corvallis Manor was understaffed; that residents’ requests weren’t addressed in a timely manner; and that food arrived late and cold. When her mom moved to a private room, it was missing a floorboard next to the window, letting in cold drafts and cigarette smoke from staff taking breaks outside, she said.
Volare Health, the Kentucky-based owner of Corvallis Manor and 10 other care facilities in Oregon, did not respond to phone calls or emails seeking comment.
The company owns Hearthstone Nursing & Rehabilitation Center, which is currently the only facility in Oregon receiving heightened oversight through the Special Focus Facility program. Placement in the program is based on a quality score that tallies the number and scope of deficiencies identified in the past three recertification surveys and the last three years of complaint investigations.
Volare also owns Corvallis Manor, designated as a candidate for the program based on its own quality score. Until December, a third Volare facility, Royale Gardens Health & Rehabilitation in Grants Pass, was also a candidate for the program.
Some complaints about Oregon nursing homes go far beyond quality-of-life issues and are ultimately substantiated as abuse and neglect by investigators. That can include physical and sexual abuse by staff or residents, medication errors, infectious disease outbreaks, or a failure to monitor a resident’s deteriorating and potentially life-threatening condition.
And some allegations, even those about a resident who ultimately died, can take months to investigate, records show.
In mid-December 2022, for example, a complaint was filed alleging that a resident at Myrtle Point Rehabilitation and Care in southern Oregon two months earlier had vomited, wasn’t eating or drinking enough and spoke in a whisper. But the allegations listed in a state report didn’t say that the person had died, according to records.
The survey unit’s investigation didn’t take place until eight months later, when surveyors conducted their annual recertification survey of the facility.
The resident referenced in the complaint died Dec. 3 after being admitted to a hospital with sepsis, a urinary tract infection, acute kidney failure and gastrointestinal bleeding, state regulators later wrote in an investigative report.
The investigation ultimately found that staff at the facility had failed to respond to the resident’s change in condition, follow physician orders or document assessments and monitoring of the individual’s condition, records show. It resulted in an immediate jeopardy finding, the most serious form of violation, when the circumstances have or could put residents at risk of injury, harm or death.
That was one of 40 deficiencies identified during the inspection, including a separate immediate jeopardy finding for failing to provide dialysis care and monitoring for another resident, resulting in pain, extensive bruising and the likelihood of severe medical complications, records show.
Elisa Williams, a spokesperson for the Department of Human Services, said in an emailed statement that the information provided in an initial complaint determines how the agency responds. With the need to prioritize available resources, she said, response times have been delayed for allegations that don’t meet the threshold for being immediately life threatening.
“The investigation may determine that the incident was more serious than the details initially reported,” she said. “The final finding reflects the facts found in the investigation.”
Sapphire Health Services, the facility’s current owner, declined to comment, saying it purchased the facility in late 2023. The previous owners, then called Continuing Care Management, did not reply to a request for comment.
A more recent recertification survey of the facility in November – 15 months after the last annual survey – identified 23 deficiencies, including a pattern of staff shortages, a failure to follow infection control standards, a failure to monitor two residents’ deteriorating conditions and a failure to prevent fall hazards, according to state licensing data. The facility is a candidate to receive special oversight, a status it’s had for more than a year.
Delayed inspections, backlogged complaints
While it can take many months to get an inspector to come out and investigate complaints, state and federal officials have different standards for the most dire concerns. Those require inspectors to respond immediately and, for the most part, that seems to happen, even if those guidelines are slipping.
When a nursing home resident’s care is compromised in a way that could cause immediate harm or even death – say a gross medication error, failing to adequately monitor a serious infection or not supervising a resident at risk of wandering away – regulators are supposed to prioritize those over less-pressing claims such as cold food or a room in disrepair.
For the most serious complaints, federal guidance says state agencies “must start the on-site investigation within three business days of receipt of the initial complaint or incident report,” or in cases where the facility has established an appropriate follow-up plan, within seven days.
It’s a standard that federal officials loosened from two to three days in 2023. And it falls far beyond the deadlines in state statute, which requires the unit to begin an investigation within two hours if a complaint alleges a resident’s health or safety is in imminent danger or the resident has recently died, been hospitalized or been treated in an emergency department.
Agency officials say that in 2019, the Centers for Medicare & Medicaid Services required the nursing survey unit to take over all complaint investigations, some of which were previously handled by a larger oversight team that conducts investigations in other long-term care settings, such as assisted living and memory care facilities. That made the mandate in state statute untenable, said Williams, the agency spokesperson.
Fred Steele, Oregon’s Long Term Care ombudsman, says delays in routine inspections and complaint investigations at nursing homes are compromising residents’ safety. Mark Graves/The Oregonian
Steele, the state ombudsman, raised concerns about the change with federal officials in 2019, saying delayed response times increase risks to residents, and that surveyors in the nursing unit didn’t have the same expertise in investigating abuse or providing protective services as specialists in the broader unit. He said he hopes the department’s outside consultant will review compliance with state law.
State data shows Oregon’s survey unit is meeting a three-day federal benchmark, on average, for responding to immediate jeopardy complaints in an average of 2.6 days. But the response time has more than doubled since 2019.
For the next tier of complaints – high priority but not immediate jeopardy – federal rules say state agencies “must initiate an on-site survey” within an annual average of 15 business days, not to exceed 18 days. That standard was also loosened in 2023 from ten business days. As of mid-October, Oregon’s response time averaged 115 calendar days, or roughly 80 business days, more than five times longer than the federal requirement.
With more complaints coming in and response times growing, the unit’s backlog of uninvestigated complaints has also remained stubbornly high. That backlog spiked during the pandemic, growing from 260 in January 2019 to nearly 1,000 two years later.
While the unit has partially worked though that logjam of older complaints, it still had 662 pending in mid-October, more than half of which were classified as high priority by the triage team.
Fast-tracked response
An exterior shot of Corvallis Manor Nursing & Rehabilitation Center in Corvallis, Oregon on Thursday, Jan. 16, 2025. Sean Meagher/The Oregonian
Knutson wasn’t aware of the extent of problems at Corvallis Manor until after she began filing complaints about the facility. And even then, it’s not clear if she received a full picture of the issues.
On her second call with regulators, she said she was told it would take nine months or more to get an inspector to investigate. When she asked what else she could do, Knutson said she was told she could check out a state website to review Corvallis Manor’s history of inspections and violations.
That’s when she realized the facility had a long list of infractions, although it’s unclear if all the problems were disclosed when Knutson visited the site.
That’s because Oregon’s website has experienced outages since last summer, leaving consumers unable to reliably access the information there. The problems came seven years after The Oregonian/OregonLive first identified shortcomings in the state’s website that excluded nearly 8,000 substantiated complaints of substandard care, with some of those omissions by design.
For the latest issue, state officials blamed a server problem that affected all daily updates to the site. The Department of Human Services in September added a note to the website warning that “some reports” weren’t available within 24 hours due to a “temporary issue.” The agency later disclosed online that its website was “not fully functioning and reports are not updating” and told families they could contact the agency via a dedicated email address with questions about a facility’s compliance record.
“The extent of the problem varies day to day,” Williams, the agency spokesperson, said in an email. Officials hope the problem is now fixed but will continue monitoring and testing.
Unsatisfied with the expected inspection delays, Knutson last year wrote a lengthy email describing her mother’s experience at Corvallis Manor to Rachel Currans-Henry, a senior adviser on human services for the governor.
“I do not accept that there is nothing to be done about the breathtakingly low level of professional care available in Benton County,” she told Currans-Henry, noting that her mom could have died.
“People’s lives hang in the balance while violations abound,” she added. “Our seniors deserve high level care in a professional and safe environment.”
The same day, Currans-Henry forwarded the email to the state ombudsman, Neufeldt and Nakeshia Knight-Coyle, the director of the Office of Aging and People with Disabilities, asking them “for your review and to take appropriate oversight actions.”
Knight-Coyle responded within two hours, writing that her team would “look into this.”
A surveyor was on site Nov. 6, two weeks later. They cited the nursing home for several issues in Knutson’s complaints: missing baseboards in some rooms, late meal service and cold food, insufficient nursing staff, and residents complaining of 20- to 40-minute waits for staff to respond to calls for assistance.
The investigator found one resident, awaiting help, “visually distraught” with soiled briefs leaking over their bed. A nearby staff member told the investigator she was behind and could not assist the resident but would ask a certified nursing assistant “as soon as I see one.”
The state fined the facility $1,500, Williams said.
But Knutson’s more serious complaint about the care her mother received was not substantiated.
“Per interviews and record review, the resident was assessed at minimum daily, staff notified the provider of many changes of condition, followed the physician orders related to lab work and transferred the resident to the hospital per the provider’s instructions,” the surveyor wrote.
Knutson, who received the state’s report in early January, scoffed at the conclusion and remains deeply frustrated. Her mother is now living at a different facility.
Her advice to other Oregonians: “Don’t leave your parents alone in these situations. You need to have eyes and ears on what’s happening day-to-day. You think they’re being taken care of, and sometimes that’s not true.”
– Ted Sickinger is a reporter on the investigations team. Reach him at 503-221-8505, tsickinger@oregonian.com or @tedsickinger
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