Oregon Living and Rehabilitation: Care Plan Failures - IL
The staff member, identified in inspection records as V14, told inspectors directly: "I had to make those appointments today, they did not have appointments made prior to today."
The two residents, identified as R1 and R7, had already been referred to a dermatologist by a previous staff member. The referrals existed. Someone had written them down and sent them somewhere. What nobody had done was schedule the actual appointments, and the gap went unnoticed until V3, the facility's wound care nurse, raised the question on the day inspectors arrived.
That question came on November 25. Not before.
Federal inspectors cited the facility under F0684, which covers the quality of care residents receive, and classified the violation as carrying potential for actual harm. The citation applied to some residents, not an isolated case.
The facility's own care planning policy, reviewed as recently as March 21, 2025, states that a comprehensive, person-centered care plan must include measurable objectives and timetables to meet each resident's physical needs, and that residents have the right to receive the services and items included in their plan of care. Referrals to outside specialists are precisely the kind of item a care plan is meant to track and complete.
For R1 and R7, that tracking failed somewhere between the referral and the phone call that was never made.
Dermatological conditions in nursing home residents are not minor administrative inconveniences. Skin integrity issues, wounds that do not heal, rashes that spread or change, infections that begin at the surface and move deeper — these are the kinds of problems that require specialist eyes, and they require them on a timeline. A referral without a scheduled appointment is not care. It is paperwork.
How long R1 and R7 waited without appointments, the inspection record does not say. What the record says is that when a nurse thought to ask the question, the answer was that no one had made the calls. And then someone did.
V14 did not explain why the appointments had not been made before November 25. The inspection record does not say whether anyone asked. What it documents is the sequence: a previous staff member sent referrals, time passed, a wound care nurse asked whether appointments existed, they did not, and a staff member scheduled them the same morning.
Oregon Living and Rehabilitation's care planning policy describes a system designed to ensure residents receive the services written into their plans. The policy was reviewed eight months before inspectors arrived. The dermatologist appointments for R1 and R7 were not scheduled until inspectors were present.
That is the distance between the policy and what happened.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oregon Living and Rehabilitation Center from 2025-11-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 22, 2026 · Our methodology
OREGON LIVING AND REHABILITATION CENTER in OREGON, IL was cited for violations during a health inspection on November 25, 2025.
Someone had written them down and sent them somewhere.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.