Hillside Heights: Pharmacy Service Lapses - OR
Both residents had been admitted to the facility in December 2025. Both went without the care their own doctors had prescribed. Nobody checked. Nobody intervened.
The facility's own bowel protocol was unambiguous. Any resident who went three days without a bowel movement was supposed to receive a nursing assessment, a physical evaluation of the gastrointestinal system, and a review of symptoms that could indicate constipation, impaction, or obstruction. If the assessment pointed to a problem, nurses were to follow physician orders that could include stool softeners, laxatives, or an enema. If none of that produced results, the physician was to be notified.
The protocol existed. The orders existed. Neither was followed.
The first resident, identified in inspection records only as Resident 5, was admitted with diabetes. A review of bowel records covering December 31, 2025 through January 28, 2026 showed the resident had no bowel movement on January 3, 4, 5, 6, or 7, five consecutive days. Progress notes and medication administration records for that stretch showed no bowel assessment was completed on any of those days. No additional bowel medications were offered.
The Director of Nursing, identified in the report as Staff 2, acknowledged the failure directly when inspectors sat down with her on January 29. She confirmed that no bowel assessment had been completed for Resident 5 and that the resident had not received the bowel care interventions the physician had ordered during those five days.
The second resident, Resident 8, had been admitted with heart failure. Bowel records from January 1 through January 29 showed no bowel movement on January 19, 20, 21, or 22, four consecutive days. Again, progress notes and medication records for that period showed no assessments completed, no additional medications offered.
The Director of Nursing acknowledged this failure as well, during a separate interview the following morning on January 30.
Constipation that goes unmanaged in nursing home residents can escalate quickly. Fecal impaction, in which stool hardens and becomes impossible to pass without medical intervention, carries serious risks including bowel obstruction. For residents with underlying conditions like diabetes or heart failure, the complications compound. Straining during bowel movements can place cardiovascular stress on patients with compromised heart function. Prolonged constipation can cause nausea, loss of appetite, and abdominal pain severe enough to disrupt sleep and recovery.
The inspection report rated the level of harm as minimal harm or potential for actual harm, and identified the problem as affecting only a few residents. Inspectors reviewed five residents total for medication administration and found the failures in two of them.
What the record does not show is whether either resident complained during those days, whether any nursing assistant noticed and flagged the issue to a nurse, or whether the gap was caught before inspectors arrived. The progress notes for those dates, according to inspectors, simply showed nothing, no assessment, no notation, no follow-up.
The facility is located at 1201 McLean Blvd. in Eugene.
The Director of Nursing confirmed both failures to inspectors without apparent dispute. What she did not explain, and what the inspection report does not resolve, is how two residents admitted within weeks of each other both fell through the same gap, in the same month, under the same protocol that the facility itself had written.
For Resident 5, five days passed. For Resident 8, four days passed. The protocol said three was already too many.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hillside Heights Rehabilitation Center from 2026-01-30 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 4, 2026 · Our methodology
HILLSIDE HEIGHTS REHABILITATION CENTER in EUGENE, OR was cited for violations during a health inspection on January 30, 2026.
Both residents had been admitted to the facility in December 2025.
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.