Hillside Heights Rehab: Unnecessary Drug Violations - OR
The inspection, completed January 30, 2026, identified the failures for both residents, each admitted to the facility in December 2025. Neither was assessed. Neither received the medications ordered under the facility's bowel protocol. Nobody called a physician.
The facility's own protocol was specific about what should happen. When a resident went more than three days without a bowel movement, a nurse was supposed to step in, conduct a physical assessment of the gastrointestinal system, check for signs of constipation, impaction, or obstruction, and interview the resident or staff. If the assessment indicated a need, the protocol called for stool softeners, laxatives, bowel stimulants, or an enema, depending on physician orders. If none of that produced a bowel movement, the physician was to be notified. It was a clear, step-by-step process.
None of it happened for either resident.
The first, identified in inspection records as Resident 5, had been 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 3rd, 4th, 5th, 6th, or 7th — five straight days. Inspectors pulled the progress notes and medication administration records for that same window. There were no bowel assessments documented. No additional medications had been offered. The Director of Nursing, identified as Staff 2, acknowledged on January 29th that the assessment had not been completed and that the resident had not received the bowel care interventions ordered during those dates.
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 19th, 20th, 21st, or 22nd. Again, inspectors reviewed the progress notes and medication records for those four days. Again, no assessments, no medications. The Director of Nursing acknowledged on January 30th that the same failures had occurred.
Constipation that goes unaddressed can progress to fecal impaction, a condition where hardened stool becomes lodged in the colon and cannot pass on its own. In older adults, particularly those with conditions like diabetes or heart failure that already affect circulation and organ function, impaction can cause serious complications, including bowel obstruction, infection, and in severe cases, perforation. The facility's own protocol existed because these risks are real and predictable. The protocol set three days as the threshold precisely because waiting longer increases the danger.
Both residents crossed that threshold. Then they crossed it again, and again, while their charts sat empty.
What makes the documentation gap notable is how complete it was. Progress notes are the daily written record nurses use to capture changes in a resident's condition and the care provided. Medication administration records track every drug given or withheld. For both residents, across a combined nine days of missed bowel movements, neither record type showed any acknowledgment that a problem existed. The nurses caring for these residents either didn't check the bowel logs, checked them and didn't act, or acted and didn't document it. The inspection report does not say which.
The Director of Nursing did not dispute the findings when confronted by inspectors. The acknowledgments came the day before and the day of the inspection's completion, suggesting the review of records had already surfaced what the daily nursing documentation had not.
Inspectors rated the harm level as minimal, with potential for actual harm. For Resident 5, who spent five days without the care the protocol required, and Resident 8, who spent four, the distinction between those two categories may have depended on what inspectors found when they finally looked.
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.
The inspection, completed January 30, 2026, identified the failures for both residents, each 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.