Laurel Hill Nursing Center
859 NE 6th Street, Grants Pass, OR 97526 · For profit - Limited Liability company · 44 certified beds · (541) 479-3700 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (4/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited Mar 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 2 actual-harm citations
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $23,465 in federal fines (most recent 2023-12-15)
- nursing-staff turnover (60%) runs well above the national median (45%)
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 3 of 5 |
| Long-stay residentspeople who live here | 2 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 21.3% | 14.9% | 15.4% | worse |
| Long-stay residents who lose too much weight | 12.1% | 4.7% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.4% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 5.1% | 2.0% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 1.4% | 4.9% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.8% | 2.4% | 3.3% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 4.5% | 12.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 87.5% | 95.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 15.2% | 5.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 16.2% | 21.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.7% | 13.9% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.0% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 81.4% | 81.2% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 33.3% | 21.4% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 21.2% | 16.1% | 12.0% | worse |
§ 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.
59.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 65 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 62.8% 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 51 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 0.61 therapist hours per resident per day in 2026Q1 — more than 88% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 25% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 59.9%CMS range 51.6–70.3 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.2%CMS range 5.7–14.7 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 62.8% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 47.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 43.1% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 73.5% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | not 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 stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 5.9% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.5%CMS range 4.0–14.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.80 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 44 beds and averages 30.1 residents a day — about 68% occupied, or roughly 14 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 5.14 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.94 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.97 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 4.60 hrs/resident/day on weekends vs 5.36 on weekdays — 14% thinner on weekends. RN hours go from 1.06 to 0.64 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 60% is well above 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
Deficiencies are fewer than at the previous inspection — improving. 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.
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.
29 citations, most serious first. The 12 most serious are shown; the remaining 17 are one tap away and print in full.
- Actual harm · G2023-12-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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 provide adequate supervision, follow care plans, complete thorough investigations and timely assess smoking for 4 of 4 sampled residents (#s 6,15, 23, and 134) reviewed for accidents. Resident 15 and Resident 134 experienced falls resulting in fractures. Findings include: 1. Resident 15 was admitted to the facility in 2022 with diagnoses including Alzheimer's disease and stroke. A 7/13/22 admission MDS and CAAs indicated Resident 15 was impaired on both sides, at risk for falls due to weakness, required increased ADL support and her/his care plan was to include interventions to reduce the risk of falls. a. A 3/10/23 revised care plan indicated Resident 15's bed would be in a low position for safety. A 3/20/23 Fall Investigation indicated Resident 15 fell out of her/his bed around 12:15 AM, her/his bed was not in the lowest position at the time of the fall. No staff interviews were completed as part of the investigation.…
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.
- Actual harm · Gcited before2022-09-16 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to ensure a surgical wound was monitored and assessed for 1 of 1 sampled resident (#177) reviewed for non-pressure skin. This resulted in Resident 177's surgical wound becoming infected, and the resident being hospitalized . Findings include: The facility's 4/2018 Skin at Risk Program Overview indicated: 16. Skin conditions other than pressure ulcers, etc. will be documented on the resident's treatment record. Other skin conditions (rashes, skin tears, excoriations, abrasions, bruises or surgical wounds) would be addressed with appropriate treatment orders. 17. The Non-Ulcer Skin Condition Evaluation would be completed weekly for wounds likely to result in complications including delayed wound healing or infections (examples: poorly approximated surgical wound or large skin tear, etc.). Resident 177 admitted to the facility on [DATE] with diagnoses including a right below the knee amputation, diabetes, and a left fifth toe amputation…
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.
- Potential for harm · Dcited before2026-01-28 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 interviews and record review it was determined the facility failed to follow physician orders for wound care interventions for 1 of 3 sampled resident's (# 101) reviewed for coordination of wound care. This placed residents at risk for unmet wound care needs. Findings include:Resident 101 was admitted to the facility in 2024 with diagnoses including a Stage 4 pressure ulcer (most severe form of pressure injury characterized by full-thickness tissue loss with exposed fascia, muscle, tendon or bone) to the sacrum (triangular bone at the base of the spine connecting the spine to the pelvis), and stroke. On 5/7/25 a BIMS evaluation indicated Resident 101 had a BIMS score of 14 and was cognitively intact. A 5/28/25 Wound Ostomy Clinic Progress Note indicated Resident 101's wound healing had stalled, and an order was faxed to the facility for the resident to get a wheelchair seat mapping completed. The order also included the facility should schedule Resident 101's seat mapping appointment. A 5/28/25 Progress Note revealed the resident returned from wound care with a new order…
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.
- Potential for harm · Fcited before2025-03-28 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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 properly follow dish sanitation practices for 1 of 1 kitchen. This placed residents at risk for food borne illnesses. Findings include: Instructions for the facility dish machine revealed the dish machine required 50 parts per million of chlorine rinse to santize. On 3/27/25 at 12:40 PM Staff 26 was observed to use the dish machine to wash dishes. Staff 26 stated she started the dish machine in the mornings when she worked and ensured chemicals were visually flowing into the dish machine to verify the chemical concentration was adequate in the dish machine. Staff 26 stated she did not know how to test for the chemcial levels of the dishwasher. The 3/2025 Sanitizing Strips and Dish Machine log indicated Staff 26 (Cook) verified the concentration of the chemical sanitation for the dishwasher was at 50 for multiple shifts on the following days she worked: 3/1/25 through 3/3/25, 3/8/25 through 3/20/25, and 3/18/25 through 3/22/25. On 3/27/25 at 1:24 PM Staff 26 stated she completed the Dish…
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.
- Potential for harm · E2025-03-28 · tag F0609 — failed to report abuse allegations — patternTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
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 report to the State Survey Agency an allegation of abuse for 3 of 3 sampled residents (#s 7, 12 and 19) reviewed for abuse. This placed residents at risk for reoccurring abuse. Findings include: 1. Resident 7 was admitted to the facility in 3/2022 with a diagnosis of dementia. The 6/2/23 care plan revealed Resident 7 had impaired cognitive function related to dementia. Staff were to ask yes/no questions to determine her/his needs. The facility's investigation revealed on 11/24/24 Staff 32 (Former CNA) reported to Staff 34 (Former LPN) Resident 7 had inappropriately touched another resident. The 1/26/25 Quarterly MDS indicated Resident 7 had mild cognitive impairment. On 3/25/25 multiple attempts were made to contact Staff 32 and Staff 18 (Former DNS) but no response was received. On 3/27/25 at 9:21 PM Staff 34 confirmed Staff 32 told her that she witnessed Resident 7 touch another resident inappropriately. Staff 34 further stated she did not report the allegation to the State Survey Agency. On 12/9/24 a…
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.
- Potential for harm · D2025-03-28 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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 observation, interview, and record review, it was determined the facility failed to protect the resident's right to be free from verbal abuse by a resident for 1 of 3 sampled residents (#12) reviewed for abuse. This placed residents at risk for abuse. Findings include: The facility's 10/2022 revised Abuse/Neglect/Misappropriation/Exploitation policy was to implement procedures designed to prevent, identify, report, and investigate potential instances of abuse and mistreatment. Resident 12 was admitted to the facility in 3/2025 with diagnoses including dementia and depression. The 3/9/25 admission MDS and Cognition CAA indicated Resident 12's cognition was moderately impaired, the resident had short and long term memory loss, and she/he was at risk for depression, anxiety, diminished psychosocial well-being, and non-participation in activities. Resident 20 was admitted to the facility in 4/2024 with diagnoses including delusional (beliefs that were contrary to reality) disorders and mild cognitive impairment. The 1/22/25 Quarterly MDS indicated Resident 20 had…
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.
- Potential for harm · D2025-03-28 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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 thoroughly investigate allegations of abuse and injuries of unknown origin for 3 of 3 sampled residents (#s 4, 7 and 19) reviewed for abuse and skin conditions. This placed residents at risk for abuse. Findings include: 1. Resident 4 was admitted to the facility in 2/2025 with diagnoses including dementia. The 2/25/25 admission MDS indicated Resident 4 had severe cognitive impairment and was never/rarely able to make decisions. The 2/25/25 Fall Risk Evaluation revealed Resident 4 had no falls within the past three months. The 2/26/25 Initial Skin Evaluation revealed no bruising. On 3/24/25 at 1:12 PM Resident 4 was observed to have a dark bruise/mark under her/his left eye that was approximately 1-inch by 1-inch. The resident was unable to be interviewed due to her/his impaired cognition. On 3/25/25 at 1:29 PM Staff 25 (LPN) stated approximately a week ago Staff 5 (CNA) reported Resident 4's black eye during the morning shift. Staff 25 confirmed sometimes it took 2 to 3 aides to help with the resident'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.
- Potential for harm · Dcited before2025-03-28 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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
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 physician orders and provide medications to treat a chronic condition for 4 of 4 sampled residents (#s 6, 19, 25, and 84) reviewed for constipation, hospice, abuse, and choices. This placed residents at risk for bowel obstruction and unmet care needs. Findings include: 1. Resident 6 was admitted to the facility in 12/2017 with diagnoses including stroke. The 1/7/25 physician's order indicated Resident 6's bowel care protocol for constipation included: -Senna (laxative medication) tablets or Miralax powder (laxative medication) may be used as needed if there was no bowel movement (BM) within 24 hours after two consecutive days without a BM. -Take one bisacodyl (laxative medication) tablet orally every 24 hours if there was no BM in three days. -Administer one bisacodyl suppository rectally every 24 hours if no BM in four days. If this occurs, notify provider. -A fleet enema (laxative medication) should be…
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.
- Potential for harm · Dcited before2025-03-28 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide 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 interview and record review it was determined the facility failed to assess a pressure ulcer at the time it was identified for 1 of 2 sampled residents (#83) reviewed for pressure ulcers. This placed residents at risk for delayed treatment and pain. Findings include: An Incident Documentation and Investigation policy revised on 10/2022 revealed an incident report was to be completed when new pressure ulcers, Stage II (partial thickness skin loss or may present as an intact or open/ruptured blister) or greater were identified. When the incident occurred, the resident was to be examined by the nurse and care provided. Once immediate care was provided, the nurse was to initiate an investigation. Resident 83 was admitted to the facility in 3/2025 with a diagnosis of a respiratory illness. Resident 83's 3/13/25 admission Profile form revealed, upon admission to the facility in 3/2025, she/he did not have a pressure ulcer. Resident 83's 3/2025 Documentation Survey Report (CNA documentation of care provided) revealed on 3/18/25, during the evening shift, a CNA identified a new…
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.
- Potential for harm · D2025-03-28 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary 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 provide appropriate dosing of medications for 1 of 6 sampled residents (#12) reviewed for medications. This placed residents at risk for complications related to medications. Findings include: Resident 12 was admitted to the facility in 3/2025 with diagnoses including atrial fibrillation (irregular heart rhythm) and high blood pressure. The 3/9/25 revised care plan indicated Resident 12 received medication for her/his atrial fibrillation and medications were to be provided according to physician orders. The 3/2025 MAR indicated to administer hydralazine (blood pressure medication) three times daily and hold for a systolic (upper number) blood pressure less than 120. Resident 12 was administered hydralazine as follows: -3/13/25 at 8:00 AM with a systolic blood pressure of 119. -3/13/25 at 12:00 PM with a systolic blood pressure of 119. -3/13/25 at 4:00 PM with a systolic blood pressure of 104. -3/18/25 at 4:00 PM with a systolic blood pressure of 108. -3/19/25 at 12:00 PM with a systolic blood pressure of…
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.
- Potential for harm · D2025-03-28 · tag F0790 — failed to provide dental care — isolatedProvide routine and 24-hour emergency dental care for each resident.
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 residents were provided dental services for 1 of 1 sampled resident (#26) reviewed for dental. This placed residents at risk for unmet dental needs. Findings include: Resident 26 was admitted to the facility in 12/2024 with a diagnosis of a stroke. Resident 26's 1/4/25 admission MDS revealed Resident 26 was alert, unable to communicate, had likely cavities, and broken molars. Resident 26's 1/13/25 Care Conference did not address if Resident 26 or her/his representative wanted Resident 26 to be assessed by a dentist for her/his identified dental issues. On 3/25/25 at 11:53 AM Resident 26 was observed to eat and did not show signs of pain while eating. On 3/26/25 at 11:07 AM Staff 17 (Social Services) stated if a resident was assessed to have dental issues on the MDS, staff were to offer dental services. Staff 17 stated she did not reach out to Resident 26's representative to offer dental services. On 3/26/25 at 11:12 AM and on 3/27/25 at 12:15 PM Staff 15 (LPN Resident Care Manager)…
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.
- Potential for harm · Dcited before2025-03-28 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview it was determined the facility failed to ensure clean items were not stored in contaminated areas for 1 of 1 laundry room reviewed for infection control. This placed residents at risk for cross contamination. Findings include: On 3/26/25 at 12:16 PM observations of the dirty side of the laundry room revealed the following: -approximately 15 pillows -four uncovered styrofoam cushions -and a triangular wedge were present on the shelf. On 3/26/25 at 12:02 PM Staff 35 (Laundry/housekeeping) stated the pillows, styrofoam cushions and a triangular wedge had been stored on the dirty laundry side for approximately one month. She reported her concerns to the maintenance director but the items were not removed. On 3/26/25 at 12:17 PM Staff 36 (Assistant Maintenance Director) confirmed he placed the pillows, styrofoam cushions, and a triangular wedge in the laundry room on the soiled linen side some time ago. He stated he did not know this was an infection control issue. On 3/28/25 at 9:20 AM Staff 1 (Administrator) and Staff 2 (DNS) were informed 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.
Show the remaining 17 citations
- Potential for harm · D2025-03-28 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure 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 residents were free from significant pain medication errors for 1 of 6 sampled residents (#16) reviewed for medications. This placed residents at risk for complications related to medications. Findings include: Resident 16 was admitted to the facility in 2/2025 with diagnoses including prostate cancer, UTI, and chronic pain. The 2/18/25 admission MDS indicated Resident 16 had constant pain throughout the day and her/his pain frequently interfered with her/his daily activities. The 2/2025 MAR revealed Resident 16 was to receive one fentanyl transdermal patch (opioid pain medication applied to the skin) every three days for 14 days beginning on 2/15/25 and to remove the old fentanyl patch when the new fentanyl patch was applied. On 2/27/25 the fentanyl patch was applied by Staff 22 (LPN). A 2/17/25 care plan indicated staff were to monitor Resident 16's pain and her/his pain medication administration. A 3/2/25 Nursing Note indicated two fentanyl patches were found on Resident 16, the resident was…
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.
- Potential for harm · F2023-12-15 · tag F0801 — widespreadEmploy 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
Based on interview and record review it was determined the facility failed to employ a director of food and nutrition services with the required certification for 1 of 1 facility reviewed for qualified dietary staff. This placed residents at risk for unmet dietary needs. Findings include: A 9/19/19 Nutrition and Food Service Training Program indicated Staff 4 (Dietary Manager) completed 270 contact hours of the program. On 12/12/23 at 11:05 AM Staff 4 indicated he did not yet pass the test for the nutrition program certification. On 12/13/23 at 1:35 PM Staff 1 (Administrator) stated she was only recently aware that Staff 4 did not possess the required certification as required.
- Potential for harm · Fcited before2023-12-15 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview it was determined the facility failed to maintain a sanitary kitchen and follow proper handwashing practices for 1 of 1 facility kitchen. This placed residents at risk for food-borne illnesses. Findings include: On 12/13/23 at 8:55 AM Staff 13 (Dietary Aide) was observed to wash her hands in a sink with dirty dishes. Staff 13's hands appeared to touch the dirty dishes in the sink before she attempted to dry her hands prior to the removal of clean dishes from the dish washer. Staff 13 stated it was difficult not to touch the dirty dishes after her hands were washed. On 12/13/23 at 11:52 AM Staff 17 (RD) acknowledged hand washing should not take place in a sink with dirty dishes and a separate hand washing sink should be used. On 12/13/23 at 1:12 PM the kitchen was observed: -The floor had a two foot by three foot outline in the vinyl flooring that was approximately one inch wide. The outline contained sections where wood underlayment was exposed. -Shelves against the wall, the top of a juice dispenser and hoses behind the juice dispenser all…
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.
- Potential for harm · E2023-12-15 · tag F0582 — patternGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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 provide information related to the Quality Improvement Organization (QIO) for 3 of 3 sampled residents (#s 234, 235, and 236) reviewed for liability and appeal notices. This placed residents at risk for accurate QIO information. Findings include: The review of three Medicare discharged residents revealed the following: -Resident 234's services ended on 9/30/23. The NOMNC (Notice of Medicare Non-Coverage) form provided to the resident did not include QIO information. -Resident 235's services ended on 10/10/23. The NOMNC form provided to the resident did not include QIO information. -Resident 236's services ended on 10/27/23. The NOMNC form provided to the resident did not include QIO information. On 12/12/23 at 12:15 PM Staff 1 (Administrator) verified there was no documentation Resident 234, Resident 235, and Resident 236 were notified of the appropriate QIO.
- Potential for harm · D2023-12-15 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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-up with residents related to their desire to formulate advance directives for 2 of 13 sampled residents (#s 4 and 20) reviewed for advance directives. This placed residents at risk for healthcare decisions in conflict with their wishes. Findings include: 1. Resident 4 was admitted to the facility in 2019 with diagnoses including heart failure and kidney disease. A 7/12/23 Social Service Progress Note indicated no advance directive was offered and Resident 4 declined to sign a declination on 7/19/19. No follow-up regarding an advance directive was found in the electronic record. An 8/7/23 Significant Change MDS revealed Resident 4 was cognitively intact. On 12/14/23 at 10:14 AM Staff 3 (Social Service Manager) stated she addressed advance directives with residents every quarter but did not document it was completed. Staff 3 acknowledged she should follow-up with Resident 4 related to her/his advance directive. 2. Resident 20 was admitted to the facility in 2022 with diagnoses including stroke and…
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.
- Potential for harm · D2023-12-15 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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 — the official record, unedited, 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 2 of 23 resident room floors. This placed residents at risk for lack of a clean and homelike environment. Findings include: On 12/12/23 at 12:38 PM room [ROOM NUMBER] was observed to have a large split and separation of the vinyl flooring revealing the wood underlayment. The flooring felt soft and spongy. On 12/14/23 at 3:33 PM room [ROOM NUMBER] was observed to have a large split and separation of the vinyl flooring revealing the wood underlayment. The flooring felt soft and spongy. On 12/15/23 at 11:58 AM Staff 5 (Environmental Service Manager) acknowledged the findings above. He stated the floors were old and needed to be replaced.
- Potential for harm · D2023-12-15 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing 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 ensure hearing aides and glasses were in place for 1 of 1 sampled resident (#21) reviewed for vision and hearing. This placed residents at risk for a decline in hearing and vision. Findings include: Resident 21 was admitted to the facility in 2022 with diagnoses including hearing loss and vision impairment. An 8/5/22 Inventory Sheet revealed Resident 21 admitted with two pairs of glasses and a single hearing aide. An 8/12/22 care plan indicated to ensure Resident 21 wore her/his glasses. There was nothing on the care plan related to the resident's hearing aids. A 11/15/23 IDT (Interdisciplinary Team) Care Conference meeting indicated the resident's significant other had concerns related to the resident not wearing her/his hearing aids and glasses. Random observations from 12/11/23 through 12/14/23 on day and evening shifts revealed Resident 21 was without her/his hearing aids and glasses. On 12/14/23 at 10:38 AM Staff 3 (Social Service Manager) stated Resident 21 came to the facility with…
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.
- Potential for harm · D2023-12-15 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review it was determine the facility failed to implement therapy recommendations, and ROM services and interventions for care for 1 of 1 resident (#15) reviewed for position and mobility. This placed residents at risk for compromised mobility and pain. Resident 15 was admitted to the facility in 2022 with diagnoses including diabetes and stroke. A 12/20/22 OT Discharge Summary revealed Resident 15 would wear a palm guard for up to five hours per day to prevent contractures (a fixed tightening or shortening of muscles or ligaments) to her/his left hand. An 10/11/23 Contracture Screening (completed by nursing) indicated Resident 15 had right wrist, fingers and thumb contractures and a skilled evaluation and restorative program was appropriate. There was no indication Resident 15 had contractures to her/his left hand. An 10/24/23 revised care plan revealed Resident 15 had an ADL performance deficit related to contractures with no goals or interventions indicated. The 11/2023 and 12/2023 TARs revealed Resident 15 refused weekly nail care five…
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.
- Potential for harm · D2023-12-15 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
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 implement trauma informed care interventions for 1 of 1 sampled resident (#9) reviewed for mood and behavior. This place residents at risk for retraumatization. Finding include: Resident 9 was admitted to the facility in 2022 with diagnoses including PTSD (Post-Traumatic Stress Disorder) and depression. A 3/6/23 Psychosocial History and Discharge form indicated Resident 9 had PTSD, did not want to share details about her/his PTSD and she/he spoke to her/his spouse for support. An 4/23/23 Annual MDS and CAAs indicated Resident 9 was mildly depressed and at risk for depression, behaviors and psychosocial well-being due to her/his diagnoses. An 10/25/23 revised care plan indicated Resident 9 had PTSD related to combat and interventions included active listening. No behavior or triggers related to Resident 9's PTSD were included. On 12/11/23 at 1:38 PM Resident 9 was observed in her/his room on her/his bed with a sheet over her/his head. Resident 9 declined an interview. On 12/12/23 at 9:01 AM Resident 9 began…
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.
- Potential for harm · D2023-12-15 · tag F0808 — failed to follow doctor-ordered diets — isolatedEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
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 therapeutic diets as ordered for 2 of 16 sampled residents (#s 15 and 18) reviewed during kitchen observations. This placed residents a risk for lack of adequate nutrition and weight loss. Findings include: An undated Nutritionally Enhanced Meals (NEM) policy indicated the NEM program added additional calories and protein to a resident's meals and could include the addition of butter, whole milk and protein enhanced soups or potatoes. 1. Resident 15 was admitted to the facility in 2022 with diagnoses including malnutrition and stroke. On 12/13/23 at 11:48 AM the meal ticket for Resident 15 revealed a NEM therapeutic diet was required. Staff 12 (Cook) was observed to plate the meal for Resident 15 and did not provide any additional calories or protein to her/his meal. Staff 12 indicated she was unaware what a NEM diet represented or the dietary requirements to implement the diet. On 12/13/23 at 11:52 AM Staff 17 (RD) stated he relied on Staff 4 to conduct the necessary trainings for…
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.
- Potential for harm · E2022-09-16 · tag F0730 — patternObserve each nurse aide's job performance and give regular training.
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 ensure CNA staff annual performance reviews were completed for 3 of 3 sampled CNA staff (#s 4, 5, and 6) reviewed for staffing. This placed residents at risk for a lack of competent staff. Findings include: The facility provided a list of hire dates for the following CNA staff: *Staff 4 (CNA), hired: 8/19/21. *Staff 5 (CNA), hired: 6/21/19. *Staff 6 (CNA), hired: 1/8/21. On 9/14/22 the facility was asked for annual performance reviews for Staff 4, Staff 5, and Staff 6. On 9/14/22 at 10:51 AM Staff 1 (Administrator) stated there were no annual performance reviews completed for Staff 4 or Staff 6 and the last one completed for Staff 5 was completed on 7/1/20. Staff 1 stated the performance reviews were not completed per hires dates annually for the staff identified.
- Potential for harm · D2022-09-16 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to provide nail care for 2 of 2 sampled residents (#s 9 and 17) reviewed for activities of daily living. This placed residents at risk for unmet needs. Findings include: 1. Resident 9 admitted to the facility in 7/2019 with diagnoses including diabetes. The 11/2/20 Care Plan indicated Resident 9 was diabetic and was to receive nail care by a licensed nurse. The 7/12/22 Annual MDS indicated Resident 9 was cognitively intact. A review of the 6/1/22-9/13/22 TARs and progress notes indicated the last time Resident 9 had nail care was on 6/16/22. On 9/12/22 at 1:53 PM Resident 9 stated it had been weeks since she/he had her/his fingernails trimmed. The resident was observed to have long, yellow jagged toenails and long fingernails. On 9/13/22 at 2:36 PM Staff 2 (DNS) observed Resident 9 and acknowledged she/he had long fingernails and toenails. Staff 2 acknowledged the last documented nail care for Resident 9 was on 6/16/22. 2.…
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.
- Potential for harm · Dcited before2022-09-16 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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 monitor, assess and treat pressure ulcers for 1 of 2 sampled residents (#3) reviewed for pressure ulcers. This placed residents at risk for unmet treatment needs. Findings include: Resident 3 admitted to the facility in 2018 with diagnoses including a pressure ulcer. The 6/29/22 Quarterly MDS indicated Resident 3 was cognitively intact. The 8/10/22 Physician Order indicated Resident 3 was to receive the following wound care: -wound mid coccyx: cleansed with saline gauze; first layer treated with silver nitrate; second layer Aqua [DATE] x 4 3/8; third layer Maple border 4 x 4 dressing changes every other day. The 8/2022 MARs and TARs indicated Resident 3 did not receive the ordered wound care to the coccyx on the following dates: -8/14/22 -8/18/22 -8/20/22 -8/22/22 -8/24/22 -8/26/22 -8/30/22 A review of the 7/2022 and 8/2022 Weekly Skin Ulcer Measurement Wound Evaluation of the coccyx indicated the following: -7/26/22: 3.8 cm length,…
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.
- Potential for harm · D2022-09-16 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 ensure a resident's CPAP (continuous positive airway pressure) machine was cleaned and tubing changed for 1 of 1 sampled resident (#25) reviewed for respiratory care. This placed residents at risk for infection due to unhygienic equipment. Findings include: Resident 25 admitted to the facility in 2/2021 with diagnoses including COPD (chronic obstructive pulmonary disease) and chronic respiratory failure. An 8/23/21 Order indicated staff were to clean the CPAP mask, filter, tubing and machine every day shift on Thursdays and as needed if soiled. The 8/21/22 Quarterly MDS indicated the resident was cognitively intact and received oxygen therapy. On 9/12/22 at 1:31 PM Resident 25 stated staff did not always clean her/his CPAP machine or change the filter. Resident 25 was unable to recall the last time the machine at been cleaned. The CPAP tubing was observed to have a brown splatter on the tubing. The 9/2022 TAR indicated staff cleaned the CPAP every Thursday and the next scheduled cleaning was…
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.
- Potential for harm · D2022-09-16 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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 resident medications did not run out for 1 of 5 sampled residents (#25) reviewed for medications. This placed residents at risk for increased pain. Findings include: Resident 25 admitted to the facility in 2/2021 with diagnoses including chronic pain and osteoarthritis. The 5/29/21 Pain Care Plan indicated staff were to administer medication per physician orders. Resident 25 had an 10/13/21 order for tramadol (narcotic pain medication) 50mg to be given every six hours PRN for pain. On 9/13/22 at 10:27 AM Resident 25 stated her/his tramadol ran out about a week ago and she/he did not receive the medication for multiple days because staff did not reorder the medication. No significant outcomes were reported as a result of Resident 25 missing the medication doses. Resident 25 stated her/his medication running out occurred multiple times previously. The 9/2022 MAR indicated the resident did not receive tramadol from 9/4/22 until 9/7/22 (three days). A 9/6/22 Nursing Note indicated Resident 25 was…
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.
- Potential for harm · D2022-09-16 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 provide the clinical rationale for extending a PRN psychotropic medication order beyond 14 days for 1 of 5 sampled residents (#17) reviewed for unnecessary medications. This placed residents at risk for unnecessary medications. Findings include: Resident 17 admitted to the facility on [DATE] with diagnoses including anxiety. An order dated 8/8/22 indicated Resident 17 received hydroxyzine (anti-anxiety medication) as needed for anxiety. An 8/17/22 Psychotropic Medication Review indicated Resident 17 received hydroxyzine as needed for anxiety and received five doses of the medication. A letter was sent regarding the duration of the hydroxyzine. Review of the 8/2022 and 9/2022 MAR indicated Resident 17 received hydroxyine one to three times a day. There was no indication in Resident 17's medical record of follow up related to the duration of the hydroxyine or a rationale from the physician related to the use of the medication beyond 14…
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.
- Potential for harm · Dcited before2022-09-16 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview it was determined the facility failed to ensure a resident's catheter was not on the floor for 1 of 1 resident (#26) randomly observed for infection control. This placed residents at risk for infection. Findings include: Resident 26 admitted to the facility in 8/2022 with diagnoses including Stage IV esophageal cancer and had a Foley catheter for comfort care. On 9/14/22 at 5:40 AM Resident 26's catheter bag and tubing were observed uncovered and laying on the floor next to the resident's bed. On 9/14/22 at 5:47 AM Staff 7 (LPN) verified Resident 26's catheter bag and tubing were on the ground which was an infection control concern. Staff 7 stated the bag and tubing ended up on the floor often as the resident moved around a lot. On 9/15/22 at 1:28 PM Staff 1 (Administrator) and Staff 8 (Administrator in Training) confirmed catheter bags and tubing were expected to be off the floor for infection control.
“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.
- 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.
Fines & penalties
$23,465 in federal fines across 1 penalty.
- $23,465 — penalty dated 2023-12-15
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 REGENCY PACIFIC MANAGEMENT — 27 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.9 | -0.9 vs chain |
| Health inspection | 3 of 5 | 3.7 | -0.7 vs chain |
| Staffing | 4 of 5 | 4.0 | ≈ chain avg |
| Quality measures | 3 of 5 | 3.6 | -0.6 vs chain |
The other 26 homes this chain runs (chain average 3.9★, per CMS)
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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| BD FACILITIES LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 100% | since 04/01/2010 |
| REGENCY PACIFIC MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2010 |
| BEDDOE, MARVIN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2010 |
| MONROE, CHRISTOPHER | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 08/28/2017 |
CMS files one row per role, so the 5 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.
2 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.
This home reported $328K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
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
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
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.
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 385232. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-28, 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 →
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