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Cottage Grove Post Acute

515 Grant Street, Cottage Grove, OR 97424 · For profit - Corporation · 80 certified beds · (541) 942-5528 Medicare & Medicaid certified

Call the home — (541) 942-5528 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citations on record (F0600, F0602) — most recent Oct 20242 actual-harm citations$20,670 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Oct 2024
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $20,670 in federal fines (most recent 2025-06-27)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
Pharmacy
1645 E Main St · (541) 942-7799 · Call to confirm hours
Grocery
77967 S 6th St · (541) 942-2645 · Call to confirm hours
Park
299 E Harrison Ave · Typically dawn to dusk
Place of worship
77873 S 6th St · (541) 942-4290

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased6.9%14.9%15.4%better
Long-stay residents who lose too much weight1.6%4.7%5.4%better
Long-stay residents with a catheter left in their bladder0.0%1.4%0.9%better
Long-stay residents with a urinary tract infection0.0%2.0%2.0%better
Long-stay residents with depressive symptoms20.6%4.9%6.5%worse
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury4.0%2.4%3.3%worse
Long-stay residents whose ability to walk worsened4.7%20.6%16.1%better
Long-stay residents on antianxiety or hypnotic medication14.0%12.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%95.2%95.3%typical
Long-stay residents with pressure ulcers5.7%5.8%4.7%worse
Long-stay residents with worsening bladder/bowel control13.6%21.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table18.8%13.9%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.1%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine89.6%81.2%79.4%better
Short-stay residents rehospitalized after admission28.1%21.4%22.6%worse
Short-stay residents with an outpatient ER visit11.5%16.1%12.0%typical

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

52.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 44 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

52.3%U.S. median 51.5%
Got home and stayed home
9.5%U.S. median 10.7%
Went back to hospital
70.8%U.S. median 56.6%
Met the expected recovery
0.65U.S. median 0.31
Therapy hours / resident / day
0.21hours / resident / day
Physical therapy
0.35hours / resident / day
Occupational therapy
0.09hours / resident / day
Speech therapy

Met the expected recovery: 70.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 24 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.65 therapist hours per resident per day in 2026Q1 — more than 90% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 32% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF52.3%CMS range 36.8–67.351.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.5%CMS range 6.2–14.210.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge70.8%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge62.5%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge37.5%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified97.8%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay4.3%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.2%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.1%CMS range 3.3–11.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.931.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.38
RN hours/ resident / day
1.08
LPN hours/ resident / day
3.18
Aide hours/ resident / day
4.64
Total nurse hours/ resident / day
0.20
RN hoursweekends
47.0%
Total nursing turnover
66.7%
RN turnover

How full it usually is: this home is certified for 80 beds and averages 65.6 residents a day — about 82% occupied, or roughly 14 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.64 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.38 is below the 0.55-hour RN benchmark and nurse-aide staffing of 3.18 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.09 hrs/resident/day on weekends vs 4.87 on weekdays — 16% thinner on weekends. RN hours go from 0.46 to 0.20 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 47% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

10
deficiencies at the latest standard inspection (2025-06-27)
6
at the previous standard inspection (2024-03-08)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

26 citations, most serious first. The 12 most serious are shown; the remaining 14 are one tap away and print in full.

  • Actual harm · G2025-06-27 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review it was determined the facility failed to provide appropriate pain management for 2 of 2 sampled residents (#s 33 and 39) reviewed for pain management. This failure resulted in Resident 39 not receiving her/his scheduled narcotic pain medications for three days which caused the resident to suffer from narcotic withdrawal, increased pain, and an avoidable hospitalization. This placed residents at risk for narcotic withdrawal and increased pain. Findings include: 1. Resident 39 admitted to the facility in 10/2024 with diagnoses including heart disease and kidney disease. Resident 39's 4/14/25 Quarterly MDS indicated the resident was cognitively intact. Resident 39 received scheduled pain medication and PRN pain medications. Resident 39 had frequent pain, which occasionally affected her/his sleep and ADLs. On 4/23/25 Resident 39 was admitted to hospice. On 6/23/25 at 11:25 AM, and 6/27/25 at 9:15 AM, Resident 39 stated two weeks ago, the facility ran out of her/his prescribed morphine. Resident 39 reported being informed by multiple…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2022-11-18 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review it was determined the facility failed to prevent the development of a pressure ulcer, failed to ensure accurate and completed wound assessments, failed to care plan the pressure ulcer and failed to demonstrate the resident's clinical condition made the development of a pressure ulcer unavoidable for 1 of 1 sampled resident (#35) reviewed for pressure ulcers. This resulted in Resident 35 developing an unstageable (full thickness skin preventing view of the depth of the wound) pressure ulcer. Findings include: Resident 35 was admitted to the facility in 10/2022 with diagnoses including heart failure and malnutrition. The 10/17/22 Significant Change CAA indicated Resident 35 was at risk for pressure ulcers related to incontinence of bowel and bladder and needed assistance with ADLs. Resident 35 had a Stage 3 (full thickness skin loss) pressure ulcer. The 10/5/22 care plan indicated the resident had bladder incontinence. The resident will remain free from skin breakdown due to incontinence and brief use A Progress Note dated 10/7/22…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-27 · tag F0636 — pattern
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to complete timely MDS assessments for 4 of 8 sampled residents (#s 20, 21, 32, and 33) reviewed for MDS and unnecessary medications. This placed residents at risk for unassessed needs. Findings include: 1. Resident 20 was admitted to the facility in 1/2025 with diagnoses including reduced mobility and muscle wasting. A review of Resident 20's clinical record revealed her/his Discharge Return Not Anticipated MDS assessment was in progress and overdue by nine days on 6/24/25. On 6/26/25 at 9:59 AM, Staff 5 (MDS Coordinator) stated she was very busy for the last two to three weeks and was behind on her work and confirmed Resident 20's MDS was late. On 6/27/25 at 7:15 AM, Staff 1 (Administrator) and Staff 2 (DNS) stated the expectation for staff was to have the MDSs completed timely. 2. Resident 21 was admitted to the facility in 7/2020 with diagnoses including kidney disease and heart failure. A review of Resident 21's clinical record revealed her/his Annual MDS assessment was in progress and overdue by 13 days…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-27 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review it was determined the facility failed to provide palatable food to 1 of 1 kitchen and 2 of 4 (#s 4 and 33) residents reviewed for food and kitchen tasks. This placed residents at risk for weight loss and reduced quality of life. Findings include: 1. A review of the 6/25/25 lunch menu revealed the facility was to provide: spaghetti with meatballs, herb green beans, and garlic bread sticks. On 6/25/25 at 11:44 AM kitchen meal service was observed. Pasta, meat sauce, garlic bread sticks, and green beans were observed to be served from the steam table. Pasta was observed to be served with tongs, appeared overcooked, and broke apart as it was served. A test tray was requested. On 6/25/25 at 12:22 PM, the test tray was sampled: -herb green beans tasted metallic and were bland. -garlic bread stick was doughy with no garlic flavor. -spaghetti noodles were mushy, soft, and overcooked. -meat sauce was flavorful but the meatball had no flavor. On 6/25/25 at 12:29 PM, Staff 9 (Dietary Manager) was asked to test the meal. Staff 9 stated the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-27 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined the facility failed to follow infection control standards for 1 of 3 halls (West Hall) and 1 of 1 sampled resident (#28) during random observations. This placed residents at risk for exposure and contraction of infectious diseases. Findings include: 1. On 6/24/25 at 10:19 AM, Resident 44 was observed touching multiple items in the PPE cart located outside room [ROOM NUMBER] for approximately five minutes. The resident opened multiple drawers and made contact with a facemask, N95 mask, and a stethoscope. Staff 28 (CNA) was standing behind the resident during this time and did not redirect the resident or sanitize the PPE cart following the interaction. On 6/24/25 at 10:26 AM, Staff 14 (LPN) asked Staff 28 to not let Resident 44 touch items in the PPE supplies. Staff 28 then re-directed Resident 44 away from the PPE cart. Staff 14 acknowledged the incident did not align with infection control protocol. On 6/26/25 at 11:43 AM, Staff 26…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-27 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review it was determined the facility failed to notify the physician of the resident's discharge to the hospital for 1 of 1 sampled resident (#39)reviewed for hospitalizations. This placed residents at risk for delayed treatment. Findings include: Resident 39 admitted to the facility in 10/2024 with diagnoses including heart disease and kidney disease. A 6/8/25 Progress Note indicated Resident 39 was sent to the hospital for nausea, diarrhea, general malaise, cold sweats, and dizziness. A review of Resident 39's clinical record revealed no indication the resident's physician was notified. On 6/25/25 at 11:44 AM, Staff 19 (Nurse Practitioner) stated she was not informed Resident 39 was sent to the hospital on 6/8/25. On 6/26/25 at 1:20 PM, Staff 2 (DNS) acknowledged Resident 39's physician was not notified when the resident was sent to the hospital.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-27 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review it was determined the facility failed to exercise reasonable care for the protection of the resident's property from loss or theft for 1 of 2 sampled residents (#38) reviewed for personal property. This placed residents at risk of loss or theft of property. Findings include: Resident 38 was admitted to the facility in 2/2025 with diagnoses including anxiety and reduced mobility. A 2/13/25 admission MDS revealed Resident 38 was cognitively intact. A 3/9/25 Grievance Concern Problem Identification and Follow-Up form indicated Resident 38 reported a concern with six packs of cigarettes missing. Steps taken revealed social services reviewed and discussed options for tracking cigarettes which came into the facility. Resident 38 did not want to store her/his cigarettes at the nurse's station because many of the locks can be opened with any key. There was no evidence of the cigarettes, so the facility would not refund or replace the cigarettes for Resident 38. Social services would place an order for maintenance to investigate the lock…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-27 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to ensure appropriate information was communicated to the receiving health care institution or provider prior to a resident being transferred to the hospital for 1 of 1 sampled resident (#39) reviewed for hospitalization. This placed the resident at risk for unassessed needs. Findings include: Resident 39 admitted to the facility in 10/2024 with diagnoses including heart disease and kidney disease. A 6/8/25 Progress Note indicated Resident 39 was sent to the hospital for nausea, diarrhea, general malaise, cold sweats, and dizziness. No evidence was found in Resident 39's clinical record to indicate the facility provided the following prior to Resident 39 being transferred to the hospital: -Contact information of the practitioner who was responsible for the care of the resident. -Advance directive information. -Medications (including when last received). On 6/27/25 at 10:19 AM, Staff 2 (DNS) stated but she was unable to provide documentation to confirm the facility provided appropriate information to the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-27 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review it was determined the facility failed to complete a Significant Change MDS assessment (SCSA) within the required 14 days after a determination of a significant change of condition of a resident for 1 of 1 sampled resident (#39) reviewed for hospitalizations. This placed residents at risk for unassessed care needs. Findings include: Resident 39 admitted to the facility in 10/2024 with diagnoses including heart disease and kidney disease. Resident 39's 4/14/25 Quarterly MDS indicated the resident was cognitively intact and was on hospice. On 6/25/25 at 10:11 AM, Staff 5 (LPN/MDS Coordinator) confirmed Resident 39 graduated from hospice on 5/30/25. Staff 5 stated she did not discuss this with Resident 39 and acknowledged she did not complete a SCSA. On 6/26/25 at 1:20 PM, Staff 2 (DNS) confirmed Resident 39 was discharged from hospice on 5/30/25 and acknowledged the facility failed to complete a SCSA for Resident 39.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-27 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review it was determined the facility failed to complete a baseline care plan within 48 hours of a resident's admission for 1 of 1 sampled resident (#32) reviewed for pressure ulcers. This placed residents at risk for unmet wound care needs. Findings include: Resident 32 was admitted to the facility in 12/2024 with diagnoses including Multiple Sclerosis (a chronic, autoimmune disease that affects the brain and spinal cord). A review of a 1/1/25 Skin & Wound Evaluation revealed Resident 32 was admitted with a Stage 3 pressure ulcer wound (a full-thickness skin loss, where the wound extends through the skin and into the fat tissue). A 6/24/25 review of Resident 32's care plan revealed no evidence of a baseline care plan for her/his Stage 3 pressure ulcer wound. On 6/24/25 at 2:38 PM, an observation of Resident 32's wound revealed a wound consistent with a Stage 3 pressure ulcer wound. On 6/26/25 at 12:43 PM, Staff 3 (LPN Care Manager) stated when a resident was admitted with a pressure ulcer wound, a care plan focused on current wound(s),…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-27 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    2. Resident 38 was admitted to the facility in 2/2025 with a diagnoses including hypertensive heart disease with heart failure (a condition where the heart cannot pump blood effectively). Physician orders with a start date of 3/15/25 instructed staff to obtain Resident 38's weight every day shift on Saturdays for weight monitoring. A review of Resident 38's weights report revealed from 3/29/25 through 6/2/25, Resident 38's weight was documented on the report as obtained out of 12 times physician ordered. The 5/2025 TAR instructed staff to obtain weekly weights every day shift every Saturday for weight monitoring with a start date of 3/15/25. The TAR was documented as NA three times, a weight of 172 one time, and a code six one time. There was no legend for what NA was defined as. Code six was indicated as glucose. Physician orders with a start date 6/20/25 instructed staff to obtain Resident 38's weight every day shift for cardiac monitoring. The 6/2025 TAR instructed staff to obtain weekly weights every day shift every Saturday for weight monitoring. The TAR was documented as NA…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-16 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to ensure resident pain medication was not misappropriated for 1 of 3 sampled residents (#3) reviewed for abuse. This placed residents at risk for increased pain. Findings include: Resident 3 was admitted [DATE] with diagnoses including a leg fracture. Review of a facility's policy Ordering and Receiving Controlled Medications dated 1/2023 revealed the facility must document and verify the quantity of controlled substances received. Review of a pharmacy medication receipt dated 9/26/24 revealed three cards of narcotic medication was delivered to the facility including medication for Resident 3. The receipt was initialed by Staff 3 (LPN). Review of the Facility Reported Incident Form (FRI) dated 9/26/24 revealed a medication card of narcotics (oxycodone 10 mg 14 tablets) for Resident 3 was missing. The form indicated the resident did not miss any doses of pain medication, the facility was searched and law enforcement was notified. Review…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
Show the remaining 14 citations
  • Potential for harm · D2024-10-16 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to store narcotic pain medications in a safe manner. This placed residents at risk for misappropriation of medications. Findings include: Review of the facility's Controlled Medication Storage policy dated 1/2024 revealed narcotic pain medication must be maintained in separately locked permanently affixed compartments. Review of a pharmacy medication receipt dated 9/26/24 revealed three cards of narcotic medication was delivered to the facility and receipt was initialed by Staff 3 (LPN). Review of the Facility Reported Incident Form (FRI) dated 9/26/24 revealed a medication card of narcotics (oxycodone 10 mg 14 tablets) for Resident 3 was missing. The form indicated the resident did not miss any doses of pain medication, the facility was searched and law enforcement was notified. Review of the Facility Reportable Incident (investigation) form dated 9/27/24 revealed on 9/26/24 between 10 PM and 10:30 PM the facility received narcotic medication for several residents all in one package. The medications were…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Past Non-Compliance
  • Potential for harm · F2024-03-08 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determine the facility failed to ensure the dietary manager had current certification for 1 of 1 kitchen reviewed. This placed residents at risk for unmet dietary needs. Finding include: On [DATE] at 10:23 AM and 3:09 PM Staff 26 (Dietary Manager) was requested to produce her Dietary Manager certification. Staff 26 stated she believed her certification as a Dietary Manager expired in 4/2023 and she was unable to located her certificate. On [DATE] at 8:30 AM Staff 1 (Administrator) acknowledged Staff 26's certification was expired.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-03-08 · tag F0730 — pattern
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 5 of 5 sampled CNA staff (#s 17, 18, 19, 20, and 21) reviewed for staffing. This placed residents at risk for a lack of competent staff. Findings include: On 12/6/22 at 9:50 AM Staff 1 (Administrator) provided the most recent performance reviews for Staff 17 (Former CNA), Staff 18 (CNA), Staff 19 (CNA), Staff 20 (CNA), and Staff 21 (CNA), which revealed the following: - Staff 17 was hired on 12/16/04; the facility was unable to provide a performance review. - Staff 18 was hired on 1/25/16; the facility was unable to provide a performance review but stated it was completed in 2020. - Staff 19 was hired on 2/6/17; the facility was unable to provide a performance review. - Staff 20 was hired on 3/2/23; the facility was unable to provide a performance review. - Staff 21 was hired on 2/1/21; the facility was unable to provide a performance review. On 3/7/24 at 11:08 AM Staff 1 (Administrator) acknowledged the performance evaluations were not…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-08 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to complete a baseline care plan within 48 hours of a resident's admission for 1 of 2 sampled residents (#253) reviewed for respiratory care. This placed residents at risk for unmet needs. Findings include: Resident 253 admitted to the facility in 2024 with diagnoses including respiratory failure and sleep apnea (repeat lapses of breathing during sleep). The 2/22/24 hospital Discharge Orders indicated Resident 253's oxygen levels were to be titrated (continuously measured and adjusted) to maintain oxygen saturations above 92 percent. A 2/23/24 progress note indicated Resident 253 required continuous supplemental oxygen during the day. The 2/23/24 baseline care plan had no information related to Resident 253's respiratory needs or equipment. On 3/6/24 at 3:23 PM Staff 27 (LPN) stated after the initial nursing assessment was completed a unit manager was to ensure the care plan was accurate. On 3/6/24 at 4:00 PM Staff 16 (LPN-Resident Care Manager) stated she was not aware Resident 253 required continuous…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-08 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review it was determined the facility failed to ensure dependent residents received assistance with nail care for 2 of 5 sampled residents (#s 15 and 18) reviewed for ADLs. This placed residents at risk for poor hygiene and unmet needs. Findings include: 1. Resident 18 admitted 2022 with diagnoses including diabetes and depression. A physician's order dated 2/7/23 directed licensed nurses to check the resident's finger and toe nails once a week on bath days and trim as needed every Tuesday evening. Staff were to document a + if nails were trimmed and a - if nails were not trimmed. Resident 18's Comprehensive Care Plan revised 2/28/24 indicated the resident often declined nail care and staff were to encourage the resident to receive nail care. According to Resident 18's 2/2024 LN Task Report she/he was scheduled for nail care on 2/6/24, 2/13/24, 2/20/24, and 2/27/24. There was no documentation on any of these days to indicate nail care was completed or refused. On 3/4/24 at 1:54 PM Resident 18 was observed to have very long finger nails on…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-08 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to follow a physician's order for daily weights for 1 of 2 residents (#14) reviewed for respiratory care. This placed residents at risk for delay in treatment. Findings include: Resident 14 admitted to the facility in 2021 with diagnoses including congestive heart failure (CHF), chronic respiratory failure and chronic obstructive pulmonary disease (COPD). According to the resident's medical record she/he was hospitalized for respiratory problems and/or CHF on 11/19/23, 12/7/23, 1/16/24, and 2/21/24. re-admission orders dated 2/25/24 directed the facility to obtain daily weights x 4 weeks for CHF. The order did not include parameters for physician notification, however the facility had standing orders from the medical director indicating if daily weights were obtained related to a diagnosis of CHF the physician was to be notified for weight gain greater than two pounds in 24 hours, three pounds in 72 hours or greater than five pounds in one week. There was no documented evidence the order was clarified to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-08 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review it was determined the facility failed to provide respiratory care and services in accordance with physician orders for 1 of 2 sampled residents (#253) reviewed for respiratory care. This placed residents at risk for unmet respiratory needs. Findings include: Resident 253 admitted to the facility in 2024 with diagnoses including respiratory failure and sleep apnea (repeat lapses of breathing during sleep). The 2/22/24 hospital Discharge Orders indicated Resident 253's oxygen levels were to be titrated (continuously measured and adjusted) to maintain oxygen saturations above 92 percent. The Oxygen Sats (saturation) Summary for Resident 253 indicated her/his oxygen level on 2/22/23 was at 91 percent and no oxygen levels were monitored from 2/27/24 through 3/1/24. A 2/23/24 progress note indicated Resident 253 required continuous supplemental oxygen during the day and the administration record was referenced. The 2/2024 TAR had no documentation of Resident 253's oxygen order or instructions related to the monitoring of her/his oxygen…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-11-18 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined the facility failed to provide a clean and well maintained environment for 5 of 30 resident room floors and 1 of 3 carpeted halls. This placed residents at risk for lack of a clean and homelike environment. Findings include: Observations made during the week of 11/14/22 through 11/18/22 revealed an area in the hallway in front of resident room eleven with carpet frayed and lifted at the seam. The carpet throughout the hall had multiple areas with dark stains and irregular shaped areas of discoloration. On 11/15/22 12:35 PM the floor in resident room [ROOM NUMBER] was observed with black and sticky areas between the bed and the window and at the foot of each bed. The areas near the dresser had large sticky yellow stains. On 11/16/22 at 12:40 PM Staff 14 (Housekeeper) stated the floors in resident rooms six, nine, 23, 28 and 29 were all difficult to clean and remained sticky because the facility no longer obtain special floor cleaning supplies. On 11/16/22 at…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-11-18 · tag F0600 — failed to protect residents from abuse and neglect — pattern
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to ensure residents were free from abuse for 3 of 5 sampled resident (#s 9, 20 and 2) reviewed for abuse. This placed residents at risk for abuse. Findings include: 1. Resident 9 was admitted to the facility in 9/2021 with diagnoses including heart failure. The 9/1/22 Annual MDS revealed the resident had a BIMS score of 15 out of 15 (cognitively intact). Resident 241 was admitted in 2/3/22 with diagnoses including dementia. A 7/23/22 Incident report indicated Staff 27 (CNA) entered Resident 9's room and noticed Resident 241 had placed a plastic wet floor sign under Resident 9's legs. Staff 27 moved Resident 241 away from Resident 9. As Staff 27 moved Resident 241 away from Resident 9's room Resident 241 grabbed Resident 9's bedside table and shoved it at her/him. The Incident report further indicated Resident 9 stated she/he was attacked while she/he slept in her/his recliner. Resident 9 stated Resident 241 came into her/his room and hit her/his legs with the wet floor sign. On 11/14/22 at 11:34 AM Resident 9…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-11-18 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 medication administration for 1 of 3 halls reviewed for late medications. This placed residents at risk for medication complications or worsening conditions. Findings include: Per Division 45 Standards and Scope of Practice for the LPN and RN [PHONE NUMBER]; Conduct Derogatory to the Standards of Nursing Defined: - Failing to dispense or administer medications in a manner consistent with state and federal law. On 12/28/21 during the morning medication pass Staff 19 (CMA) reported Residents 29, 15 and 22 on East hall informed her they did not receive their morning medications on 12/27/21. On 12/28/21 at 11:15 AM the facility conducted a medication administration report audit which revealed the following: Resident 29's 12/2021 MAR revealed: -Pantoprazole (stomach medication) scheduled at 7:00 AM before breakfast was documented as administered at 8:34 AM -Acarbose (diabetic medication)…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-11-18 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to ensure narcotic records were reconciled based on standards of practice for 3 of 3 halls reviewed for narcotic reconciliation. This placed residents at risk for misappropriation of medications. Findings include: On 11/17/22 at 10:19 AM observations of the facility's narcotic books for the last three months to current revealed: -The South hall book 1 had 23 of 30 days in 9/2022, 12 of 14 days in 10/2022 and 9 of 17 days in 11/2022 for which there was lack of reconciliation evidence. -The South hall book 15 had 26 of 30 days in 9/2022, 24 of 31 days in 10/2022 and 7 of 17 days in 11/2022 for which there was lack of reconciliation evidence. -The East hall book had 19 of 30 days in 9/2022, 18 of 31 days in 10/2022 and 9 of 17 days in 11/2022 for which there was lack of reconciliation evidence. -The [NAME] hall PRN book had 26 of 30 days in 9/2022, 21 of 31 days in 10/2022 and 4 of 17 days in 11/2022 for which there was lack of reconciliation evidence. -The [NAME] hall book had 18 of 30 days in 9/2022, 16 of 31…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-11-18 · tag F0760 — failed to prevent significant medication errors — pattern
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to ensure significant medication errors did not occur for 7 of 17 residents (#s 12, 15, 16, 19, 22, 29 and 30) reviewed for medication administration times. This placed residents at risk for seizures, blood sugar, stomach and blood pressure issues and medication complications. Findings include: On 12/28/21 during the morning medication administration Staff 19 (CMA) was told by several residents they did not receive their medications on the morning of 12/27/21. A facility audit conducted on 12/28/21 of the morning medication administration for 12/27/21 revealed multiple episodes of late medication administration. On 12/28/21 at 11:15 AM the facility conducted a medication administration report audit which revealed the following: 1. Resident 29 was admitted to the facility in 2021 with diagnoses including diabetes. Resident 29's 12/2021 MAR revealed: -Pantoprazole (stomach medication) scheduled at 7:00 AM before breakfast was documented as administered at 8:34 AM -Acarbose (diabetic medication) scheduled three…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-11-18 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to provide assistance with a bedpan for 1 of 1 sampled resident (#91) reviewed for ADLs. This placed residents at risk for skin breakdown. Findings include: Resident 91 was readmitted to the facility in 8/2022 with diagnoses including hemiparesis (partial paralysis on one side of the body). A 3/29/22 revised care plan revealed Resident 91 had an ADL self-care performance deficit and required two-person total assist with toileting, offer the bedpan to encourage continence and recheck per standard of care. A 9/8/22 FRI investigation indicated Resident 91 was found on a bedpan and stated she/he was placed on the bedpan at approximately 4:30 PM. On 11/15/22 at 2:37 PM Staff 16 (LPN) stated on 9/8/22 day shift reported to Staff 24 (CNA) Resident 91 was on a bedpan. On 11/15/22 at 12:32 PM Staff 24 stated she received report at 2:30 PM from day shift Resident 91 was on a bedpan. Staff 24 stated she saw Resident 91's call light on but thought another CNA answered the light so she did not check on the resident. On…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-11-18 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to follow physician orders and care plan for 3 of 8 sampled residents (#s 2, 28 and 33) reviewed for medications and ADLs. This placed residents at risk for unmet needs. Findings include: 1. Resident 28 was admitted to the facility in 7/2021 with diagnoses including chronic pain and diabetes. A 6/23/22 physician's order revealed a Fleet Enema (saline enema) was to be administered every 72 hours as needed if no bowel movement occurred on the following shift after a Dulcolax suppository (stool softener) application. The nurse practioner must also approve if the Fleet Enema was administered again before three days. A 11/5/22 progress note revealed Resident 28 received bowel care after no bowel movement for three days. The 11/2022 MAR revealed Resident 28 was provided an enema on 11/6/22 and 11/7/22. The 11/2022 TAR revealed Resident 28 was not provided a Dulcolax Suppository prior to the administration of the enema. Resident 28's clinical record revealed the nurse practioner was not notified about the use of the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$20,670 in federal fines across 1 penalty.

  • $20,670 — penalty dated 2025-06-27

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to PACS GROUP — 274 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 52.9+0.1 vs chain
Health inspection 3 of 52.5+0.5 vs chain
Staffing 4 of 52.5+1.5 vs chain
Quality measures 4 of 54.4-0.4 vs chain
The other 273 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Anchor Post AcuteAiken, SC 1 of 5Arbor Post AcuteChico, CA 1 of 5Artesia Palms Care CenterArtesia, CA 1 of 5Arvin Post AcuteArvin, CA 1 of 5Ashland Post AcuteAshland, OR 1 of 5Bakersfield Post AcuteBakersfield, CA 1 of 5Beachwood Post-Acute & RehabSanta Monica, CA 1 of 5Brookshire Post AcuteDenver, CO 1 of 5Brushy Creek Post AcuteGreer, SC 1 of 5Buckeye Care And RehabilitationLancaster, OH 1 of 5Carnegie Park Post AcutePittsburgh, PA 1 of 5Cascade Terrace Post AcutePortland, OR 1 of 5Centennial Post AcuteAnchorage, AK 1 of 5Chandler Creek Post AcuteGreer, SC 1 of 5Chehalem Post AcuteNewberg, OR 1 of 5Country Hills Post AcuteEl Cajon, CA 1 of 5Delhi Post-AcuteCincinnati, OH 1 of 5Dublin Post AcuteDublin, OH 1 of 5Edisto Post AcuteOrangeburg, SC 1 of 5Evan Terrace Post AcuteMcMinnville, OR 1 of 5Forest Acres Post AcuteColumbia, SC 1 of 5Grandview Post AcuteCookeville, TN 1 of 5Great Plains Post AcuteWichita, KS 1 of 5Hemet Hills Post AcuteHemet, CA 1 of 5Highland Hills Post AcutePittsburgh, PA 1 of 5Highline Post AcuteDenver, CO 1 of 5Johns Island Post AcuteJohns Island, SC 1 of 5Karcher Post AcuteNampa, ID 1 of 5Kennedy Care CenterLos Angeles, CA 1 of 5Kern River Transitional CareBakersfield, CA 1 of 5Lakeview Post AcuteFlorissant, MO 1 of 5Marion Valley Post AcuteMarion, OH 1 of 5Mirage Post AcuteLancaster, CA 1 of 5Monroeville Post AcuteMonroeville, PA 1 of 5Napa Post AcuteNapa, CA 1 of 5North Royalton Post AcuteParma, OH 1 of 5Northstar Post AcuteCarson City, NV 1 of 5Overland Park Post AcuteOverland Park, KS 1 of 5Pikes Peak Post AcuteColorado Springs, CO 1 of 5Ridgeway Post AcutePetaluma, CA

Showing 40 of 273; lowest-rated first.

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
TRUIST BANKOrganization5% OR GREATER SECURITY INTERESTsince 09/01/2024
APT, FREDERICKIndividualOPERATIONAL/MANAGERIAL CONTROLsince 05/10/2024
BARR, JENNIFERIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/29/2025
JERGENSEN, JOSHUAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 05/10/2024
MITCHELL, JOHNIndividualOPERATIONAL/MANAGERIAL CONTROLsince 05/10/2024
POMPEY, KARENIndividualOPERATIONAL/MANAGERIAL CONTROLsince 11/21/2024
WALLENKAMPF, VICTORIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/29/2025
COTTAGE GROVE 515 REALTY LLCOrganizationADP OF THE SNFsince 09/01/2024
PROVIDENCE ADMINISTRATIVE CONSULTING SERVICES INCOrganizationADP OF THE SNFsince 09/01/2024

CMS files one row per role, so the 11 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$9.3M
Net patient revenuemost recent cost report
+11.3%
Operating marginrevenue minus expenses
$730K
Related-party expense9% of expenses
Who pays — share of resident-days
Medicaid 74%Medicare 4%Other / private 22%

About 74% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $730K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$488per resident / day
operating cost
$14,830per month
≈ monthly operating cost
$550per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in OR

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Oregon Medicaid page.

Typical monthly cost in Oregon
$16,760/mo
Nursing home (semi-private)
$18,448/mo
Nursing home (private)
$6,875/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 385152. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-27, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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