Fairlawn Health And Rehabilitation Of Cascadia
3457 NE Division Street, Gresham, OR 97030 · For profit - Corporation · 82 certified beds · (503) 667-1965 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (34% vs 45% nationally) — better care continuity
- it has 1 actual-harm citation
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
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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 | 3 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 3 to 5 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 | 21.5% | 14.9% | 15.4% | worse |
| Long-stay residents who lose too much weight | 16.6% | 4.7% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.0% | 1.4% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.0% | 2.0% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 4.9% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.5% | 2.4% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 13.5% | 20.6% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 19.3% | 12.4% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 96.4% | 95.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.3% | 5.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 27.4% | 21.8% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.0% | 13.9% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.6% | 1.4% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 85.7% | 81.2% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 22.4% | 21.4% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 24.0% | 16.1% | 12.0% | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
§ 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.
63.5% 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 114 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 56.5% 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 46 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 0.48 therapist hours per resident per day in 2026Q1 — more than 79% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 43% 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 | 63.5%CMS range 53.5–71.8 | 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 | 9.7%CMS range 6.5–13.3 | 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 | 56.5% | 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 | 45.6% | 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 | 45.6% | 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 | 100.0% | 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 | 2.6% | 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 | 6.9%CMS range 4.1–11.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.90 | 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 82 beds and averages 74.6 residents a day — about 91% occupied, or roughly 7 beds typically open. It runs fairly full. 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 4.76 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.84 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.43 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 4.29 hrs/resident/day on weekends vs 4.96 on weekdays — 13% thinner on weekends. RN hours go from 0.92 to 0.66 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 34% is below 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.
27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.
- Actual harm · Gcited before2020-01-21 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 8 sampled residents (#107) reviewed for medications. As a result, Resident 107 received a diabetic medication, she/he did not have a diabetic condition, and experienced seizure activity due to severe hypoglycemia (low blood sugar) with a blood sugar level of 19 upon arrival at the hospital. Resident 107's blood sugar levels did not stabilize and she/he became unresponsive and was transferred to the hospital. Findings include: Resident 107 was admitted to the facility on [DATE] with diagnoses including prostate cancer, heart disease and heart failure. The admission did not include a diagnosis of diabetes and monitoring of blood sugar levels. The 5/13/19 admission MDS assessment revealed Resident 107 had a BIMS score of 10 (moderately impaired cognition). She/he was not coded for a diabetic condition and did not receive diabetic medication. Resident 107's care plan…
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 before2026-03-27 · 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 ensure food was labeled and stored in a manner to avoid spoilage in 2 of 2 kitchens and failed to properly follow dish sanitizing practices and sanitization of food preparation surfaces for 1 of 2 kitchens. This placed residents at risk for food-borne illnesses. Findings include:Review of the US FDA 2022 Food Code indicated the following:-Food prepared and held cold must be clearly marked with date prepared or by day which the food shall be consumed or discarded.-Food must be labeled with a use-by-date if stored for at least 24 hours.-Food could be stored up to seven days.The facility's Food Safety and Storage policy, dated 11/28/2017, indicated the facility stored and handled all food, non-food items and food preparation supplies in a manner that ensured safety, sanitation and compliance with federal, state and local regulations. Practices followed the FDA Food Code (2022). 1. On 3/23/26 between the hours of 9:33 AM and 9:59 AM, a brief tour was completed of both facility kitchens,…
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 before2026-03-27 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 precautions for 2 of 3 sampled hallways (north hall and west hall) reviewed for infection control. This placed the residents at risk of acquiring an infection. Findings include:According to the Center for Disease Control and Prevention (CDC) website https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html: -Use contact precautions for patients with known or suspected infections that represent an increased risk for contact transmission. -Use personal protective equipment (PPE) appropriately, including gloves and gowns. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. According to the Centers for Disease Control and Prevention (CDC)'s 6/2021 Consideration for Use of Enhanced Barrier Precautions…
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 · Ecited before2026-03-27 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure 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 the facility failed to ensure the resident meals were served at an appetizing temperature in hallways for 1 of 1 facility reviewed for food. This placed residents at risk for inadequate nutritional intake. Findings include:Review of the 12/2025, 1/2026 and 2/2026 Resident Council meeting notes revealed the Resident Council expressed food concerns including hot food served cold.Resident 36 was admitted to the facility in 2/2026 with a diagnoses including sepsis (body's extreme response to an infection damaging tissue and organs) and nutritional deficiency.A 2/12/26 admission MDS assessed Resident 36 as cognitively intact. Resident 69 was admitted to the facility in 3/2026 with a diagnoses including occlusion and stenosis of the left posterior cerebral artery (condition where the main vessel supplies blood to the brain).A 3/9/25 admission MDS assessed Resident 69 as cognitively intact.Resident 90 was admitted to the facility 3/2026 with a diagnoses including a fractured tibia (shinbone).A 3/18/26 admission MDS assessed Resident 90 as…
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 · Ecited before2024-12-06 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 ensure food and beverages were labeled and stored in a manner to minimize spoilage and cross contamination for 1 of 1 kitchen reviewed for sanitary conditions. This placed residents at risk for foodborne illness. Findings include: 1. The facility's 4/2018 Food Storage: Cold Foods Policy Statement specified, All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. The facility's 9/2017 Food Storage: Dry Goods Policy Statement specified, All packaged and canned food items will be kept clean, dry, and properly sealed. On 12/2/24 at 9:43 AM during the initial tour of the facility's kitchen, the following was observed: -Three trays of unlabeled and undated cups of milk and juice on the top shelves of the middle and right refrigerators in the food preparation area; -An uncovered and unlabeled large plastic bin of dry oat cereal sitting on the top shelf of a wheeled cart in the dry storage room; -An opened and undated…
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 · D2024-12-06 · 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 ensure a homelike environment for 1 of 2 resident rooms (room [ROOM NUMBER]) reviewed for environment. This placed residents at risk for a lessened quality of life. Findings include: An observation on 12/2/24 at 9:56 AM revealed the cloth recliner chair in room [ROOM NUMBER] was stained with an unknown brown dried residue on the seat of the chair and on the arm rests. On 12/4/24 at 2:14 PM Staff 10 (CNA) stated the chair in room [ROOM NUMBER] was filthy and did not have a cleanable surface. On 12/4/24 at 2:23 PM Staff 3 (Infection Preventionist) stated the chair was very dirty and did not have a cleanable surface. On 12/6/24 at 12:54 PM Staff 12 (Housekeeping) stated she had a monthly cleaning schedule for resident recliners but did not clean the one in room [ROOM NUMBER] because it was cloth. On 12/6/24 at 2:20 PM Staff 1 (Administrator) confirmed the chair was dirty and had a bad odor.
- Potential for harm · D2024-12-06 · tag F0660 — isolatedPlan the resident's discharge to meet the resident's goals and needs.
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 safe discharge for 1 of 2 sampled residents (#210) reviewed for safe discharges. This placed residents at risk for unmet care needs. Findings include: Resident 210 was admitted to the facility in 7/2024 with diagnoses including periprosthetic fracture around other internal prosthetic joint (a bone fracture that occurs near or around a joint replacement implant). Resident 210's 7/31/24 St. Louis University Mental Status Examination (SLUMS) score indicated the resident experienced dementia. Resident 210's 9/5/24 Discharge MDS Assessment revealed the resident was cognitively intact, had an indwelling catheter, was occasionally incontinent of urine, required setup or clean-up assistance with showering and to put on or take off foot wear and required supervision or touch assistance with car transfers and to go up or down a curb or one step. Resident 210's 9/5/24 Physician Orders directed the resident to receive hydralazine (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 · Dcited before2024-12-06 · 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 ensure safety interventions for fall prevention were followed for 1 of 4 residents (#26) reviewed for accidents. This placed residents at risk for accidents. Findings include: Resident 26 was admitted to the facility on [DATE] with diagnoses including age-related osteoporosis with a current pathological fracture of her/his left femur (a chronic disease that causes bones to become brittle and porous, and a broken upper-leg bone) and severe vascular dementia with agitation (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain). A review of Resident 26's 9/30/24 Quarterly MDS Assessment revealed she/he had severe cognitive impairment. Resident 26's 9/30/24 Quarterly Fall Risk Assessment indicated she/he was at risk for falls related to her/his incontinence, impaired cognition and impaired functional mobility. A review of Resident 26's care…
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 before2024-12-06 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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 follow catheter care orders for 1 of 1 resident (# 53) reviewed for catheter care. This placed residents at risk for unmet care needs. Findings include: Resident 53 was initially admitted to the facility in 10/2024 with diagnoses including urine retention (difficulty urinating) with the use of a Foley catheter to remove urine from the bladder. A 10/3/24 BIMS indicated Resident 53 had normal cognitive function. A 12/3/24 Neurosurgery Postoperative Visit note included instructions for Resident 53's Foley catheter to be changed after she/he returned to the nursing facility. A 12/3/24 physician order stated the following: Change Foley ASAP, was not changed during hospitalization. On 12/4/24 at 9:53 AM Resident 53 stated she/he returned to the facility after a surgical procedure at the hospital and had orders to have her/his catheter changed immediately. Resident 53 stated her/his Foley catheter was not changed on 12/3/24. On 12/5/24 at 9:50 AM Resident stated her/his Foley catheter was not changed…
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 · D2024-11-21 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
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 discharge summary for 1 of 3 sampled residents (#1) reviewed for discharge. This placed residents at risk for unmet discharge needs. Findings include: Resident 1 admitted to the facility on 8/2023 with diagnoses including malnutrition. Resident 1's care plan, revised 9/29/23, revealed she/he planned to discharge home and the facility would make referrals for home health, physical and occupational therapy, and other medically related services. On 11/18/24 at 11:05 AM, Staff 4 (Social Services Director) stated she was responsible for resident discharges. She stated she made community referrals including home health, faxed physician orders to community providers and completed discharge summaries as part of the discharge process. She confirmed Resident 1 did not have a discharge summary in her/his clinical record in 2023. On 11/19/24 at 10:16 AM, Witness 1 (Home Health Staff) stated she attended a care conference a couple of days before Resident 1 discharged last year. The facility agreed they would…
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 before2024-11-21 · 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 follow physician orders for 2 of 3 sampled residents (#s 3 and 4) reviewed for bowel care. This placed other residents at risk for bowel complications. Findings include: On 3/31/24, the Past Noncompliance was corrected when the facility implemented an updated bowel protocol, which included: -Bowel protocol binders are located at each nursing station; -New bowel forms were created for every resident and reviewed daily; -Residents with no documented bowel movement after 72 hours were added to the list, monitored and followed up by nursing staff; -Staff in-serviced on the facility's bowel protocol. -Interviews conducted with nursing staff and confirmed bowel protocol was in place. 1. Resident 3 admitted to the facility in 9/2023, with diagnoses including atrial fibrillation and constipation. Resident 3's physician orders dated 9/28/23 indicated she/he was to be administered bowel medications daily. The bowel protocol on 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.
Show the remaining 16 citations
- Potential for harm · Dcited before2024-05-24 · 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 interview and record review it was determined the facility failed to follow physician orders for medication administration for 1 of 3 residents (# 501) reviewed for medication administration timeliness. This placed residents at risk for reduced medication efficacy and adverse medication side effects. Findings include: Resident 501 was admitted to the facility in 9/2023 with diagnoses including a urinary tract infection (UTI). Physician Orders from 10/2023 included orders for the following medications to be administered at 7:15 AM: - Polyethylene Glycol Power - Give 17 grams in the morning for bowel care. - Potassium Chloride ER - Give half a tablet by mouth in the morning for supplement. - Torsemide 100 mg - Give one tablet by mouth in the morning for heart health. - Cipro 500 mg - Give one tablet by mouth twice a day for UTI for 10 days. (Started 10/10/23). - Nitrofurantoin Macrocrystal 100 mg - Give one capsule by mouth in the morning for UTI prevention. (Started 10/20/23). Review of a 10/2023 Medication Admin Audit Report revealed the following delays in 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.
- Potential for harm · Dcited before2023-10-18 · 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 administer Warfin (blood thinner) as ordered which resulted in a significant medication error for 1 of 3 sampled residents (#1) reviewed for medication administration. The placed the resident at risk for adverse side effects of medications. Findings include: Resident 1 was admitted to the facility in 2023 with diagnoses including heart failure, chronic kidney failure, and atrial fibrillation. Resident 1's admission MDS identified Resident 1 with a BIMS score of 13 out of 15 which indicated no cognitive impairment. Resident 1's signed Physician Order's revealed Resident 1 was ordered Warfin 2.5 mg by mouth every Monday, Friday, Saturday, and Sunday at bedtime to treat Resident 1's diagnosis of Atrial Fibrillation. A 9/4/23 Incident Note revealed Staff 7 identified and documented that Resident 1 missed 3 doses of Warfin on Friday, 9/1/23, Saturday, 9/2/23 and Sunday 9/3/23. The 9/2023 MAR revealed on Friday 9/1/23, Saturday 9/2/23, and Sunday 9/3/23, Resident 1 was not administered Warfin as prescribed by…
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 before2023-08-29 · 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 follow physician orders for 1 of 3 sampled residents (#1) reviewed for respiratory care and bowel care. This placed other residents at risk for unmet needs. Findings include: Resident 1 admitted to the facility in 7/2023 with diagnoses including congestive heart failure, emphysema and muscle weakness related to falls. a. Resident 1's 7/17/23 care plan interventions for her/his respiratory symptoms included wearing a CPAP/BIPAP (a machine that regulates lung airflow and helps with breathing) while sleeping. Physician Orders dated 7/18/23 instructed Resident 1 use a BIPAP one time a day related to sleep apnea. Nursing assessments and notes revealed Resident 1 had a history of hypercapnia (high levels of carbon dioxide in the blood) and had not consistently used her/his CPAP while living at home. Nursing notes dated 8/19/23, 8/20/23 and 8/21/23 revealed the CPAP machine's tubing was missing after she/he moved rooms. There was no…
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 before2020-01-21 · 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 appropriately prepare, distribute, serve and store kitchen cookware for 2 of 2 kitchens reviewed for food services quality. This placed residents at risk for contaminated food. Findings include: 1. On 1/15/20 at 3:43 PM eight pans in the main kitchen were observed to be stacked wet in the dry storage area. In an interview on 1/15/20 at 3:45 PM Staff 15 (Cook) stated that the pans were not usually stacked wet and the pans needed to be air dried prior to being stacked. On 1/17/20 at 2:19 PM, Staff 1 (Administrator) confirmed she expected pans to be stacked dry. 2. The 7/2018 Employee Hygiene and Dress Code for Good and Nutrition Services revealed hairnets or hair restraints are used when in the food preparation kitchen including dish rooms and storage rooms. Hair is to be covered completely. On 1/16/20 at 7:12 AM through 7:27 AM Staff 16 (Dietary Aide) was observed with her bangs outside the hairnet while handling plates of food in the kitchen. On 1/16/20 at 11:35 AM Staff 16 and Staff 17 (Cook)…
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 · E2020-01-21 · tag F0577 — patternAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
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 inform residents of the location of 1 of 1 State survey inspection results and failed to ensure the survey results were readily accessible. This placed residents and public at risk for lack of knowledge regarding quality of care and quality of life concerns within the facility. Findings include: On 1/15/20 at 11:23 AM ten of ten members of the resident council group interview, responded they were unaware of where to access a copy of and what the facility's survey results were without asking facility staff. On 1/15/20 at 11:35 AM no facility State survey results were found on any of the 3 halls, in the prayer lobby and at the nurse's station. On 1/15/20 at 1:34 PM a binder labeled RECENT SURVEY was observed at the front reception desk behind a potted plant, tucked in a gap between the wall and the glass to the reception desk with approximately four inches of the binder exposed from the nook-like gap. The survey binder was not visible or accessible to someone sitting in a wheelchair or walking by. On 1/16/20…
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 · E2020-01-21 · tag F0732 — patternPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview and record review it was determined the facility failed to ensure the daily staff posting was accurate for 107 out of 107 days reviewed for staffing. This placed residents, public and staff at risk for lack of accurate staffing information. Findings include: On 1/13/20 at 9:02 AM and 1/15/20 at 5:20 PM, the Direct Care Staff Daily Report was observed prefilled with completed information for all shifts and had not been completed at the beginning of each shift on a daily basis. On 1/16/20 at 1:59 PM, the Direct Care Staff Daily Reports were provided by facility from 10/1/19 through 1/15/20. The reports had no corrections made on the sheets and the signatures were of the same person completing all three shifts. On 1/17/20 at 8:25 AM, Staff 1 (Administrator) acknowledged the Daily Staffing reports were not completed at the beginning of each shift and were completed at the start of the day or evening prior.
- Potential for harm · Ecited before2020-01-21 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to ensure meals were palatable, attractive and served at an appropriate temperature for 2 of 3 halls and 2 of 2 sampled residents (#s 45 and 55) reviewed for food quality. This placed residents at risk for unmet needs. Findings include: 1. Resident 55 was admitted to the facility on [DATE] with diagnoses including wound care. The 12/2019 admission MDS revealed Resident 55 had a BIMS score of 15, which indicated she/he was cognitively intact. Resident 55 was assessed to eat independently and she/he did not have any swallowing disorders. On 1/13/20 at 10:48 AM, Resident 55 stated the vegetables were mushy. Resident 55 stated that she/he had been given an inadequate amount of food for breakfast and was still hungry. Resident 55 stated she/he was unaware that snacks or alternative food could be requested. Resident 55 stated she/he had observed the food cart in the hall on dinner shift. She/he stated it took a while for the food…
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 · D2020-01-21 · 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 record review and interview it was determined the facility failed follow up on advance directives for 1 of 5 sampled residents (#20) reviewed for advanced directives. This placed residents at risk for choices not being honored. Findings include: The 4/2016 Advance Care Planning and Advanced Directive policy revealed Purpose: to provide each resident the opportunity to make decisions regarding future medical care and select a proxy .to define a process to assist residents or families and healthcare decision makers in advanced care planning. Resident 20 was admitted in 10/2012 with diagnoses including dementia. The 2/13/19 Advanced Care Planning note revealed an annual review of the POLST (portable orders for life sustaining treatment) form. The resident was unable to comprehend or discuss her/his POLST and the family was not available for discussion. Will continue with the current POLST. No additional documentation was found or provided by the facility to ensure the resident's representative was offered the opportunity to provide information if Resident 20 had an advanced…
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 · D2020-01-21 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately 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 — 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 resident's representative was notified of a new medication and treatment order for 1 of 8 sampled residents (#107) reviewed for medications. This placed residents at risk for being administered medication and treatments for a condition the resident did not have. Findings include: The facility's Medication - Administration, Including Scheduling and Medication Aides policy and procedure revised in 1/2020 revealed The resident and/or legal representative will be notified of new medication orders and the risk/benefit of the medications. All discussions will be documented in the medical record . Resident 107 was admitted to the facility on [DATE] with diagnoses including prostate cancer, heart disease and heart failure. The 5/13/19 admission MDS assessment revealed Resident 107 had a BIMS score of 10 (moderately impaired cognition). She/he was not coded for a diabetic condition and did not receive diabetic medication. Resident…
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 · D2020-01-21 · tag F0636 — isolatedAssess 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 observation, interview and record review it was determined the facility failed to comprehensively assess the use of an urinary catheter for 1 of 1 sampled resident (#6) reviewed for catheters. This placed residents at risk for unassessed needs. Findings include: Resident 6 was admitted to the facility in 6/2019 with diagnoses including hypertensive chronic kidney disease. Resident 6 was observed from 1/13/20 at 4:46 PM through 1/15/20 at 4:14 PM with a urine catheter bag and tubing. The Significant Change of Condition MDS Assessment completed 10/1/19 indicated Resident 6 had no use of a urinary catheter. A 10/25/19 Urology note indicated Resident 6 had a catheter placed for incontinence. Record review revealed no ongoing assessment which identified the resident risk and benefits for urinary catheterization, plan for removal when no longer necessary or consideration of complications from the use of an indwelling (tube into bladder) catheter. During an interview on 1/15/20 at 4:15 PM, Staff 3 (RNCM) confirmed Resident 6 had no assessment for the indwelling catheter. Staff 3…
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 · D2020-01-21 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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 develop a resident centered care plan for 3 of 6 sampled residents (#'s 3, 17 and 56) reviewed for activities, communication and nutrition. This placed resident at risk for unmet needs. Findings include: 1. Resident 3 was admitted to the facility in 3/2018 with diagnoses including anxiety. Resident 3's 4/3/19 Annual MDS revealed the resident required a Vietnamese translator for more complex communication. The residents family members and two staff assisted with language translation. A communication tool with pictures to help enhance communication had been placed in her/his room to help with communication when family and our Vietnamese speaking staff members were not available. A 4/3/19 care plan note indicated Resident 3's communication tool had been missing from her/his room and a new communication tool had been placed in her/his room. Resident 3's care plan review on 1/17/20 at 10:09 AM indicated intervention of a communication tool with pictures to help enhance communication when family…
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 · D2020-01-21 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
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 an ongoing program of activities designed to meet the interests and psychosocial well-being for 1 of 2 sampled residents (#17) reviewed for activities. Failure to provide meaningful and regular activities placed residents at risk for unmet psychosocial needs. Findings include: Resident 17 was admitted to the facility in 7/2018 with diagnosis including major depression and dementia. Resident 17's 7/26/19 Activity Assessment identified she/he enjoyed going on outings. Resident 17's 7/28/19 Annual MDS identified it was very important for her/him to go outside and participate in her/his favorite things. Review of the 10/2019, 11/2019, 12/2019 and 1/2020 Activity Calendars revealed no group outings were scheduled for residents. During an interview on 1/14/20 at 10:56 AM, Resident 17 reported she/he did not have the opportunity to go on outings with the facility. On 1/17/20 at 7:47 AM, Witness 1 (Facility Staff) reported the facility had not provided the residents an opportunity for outings into 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.
- Potential for harm · Dcited before2020-01-21 · 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
Based on observation, interview and record review it was determined the facility failed to keep a medication needle attended and out of residents' access for 1 of 5 sampled residents (#19) reviewed for accidents. This placed residents at increased risk for injury. Findings include: Resident 19 was admitted to the facility in 10/2019 with diagnoses including Type 2 Diabetes and major pain. The physician order for Resident 19 revealed the resident was injected (by needle) Lispro (insulin) subcutaneously (under skin) before meals as ordered. On 1/16/20 at 9:05 AM, an observation was made in Resident 19's room with a medication needle left on her/his bedside table. On 1/16/20 at 9:06 AM, Staff 9 (LPN) confirmed the medication needle was left on Resident 19's bedside table. Staff 9 stated all needles should be disposed of in the sharps container after use. On 1/21/20 at 8:46 AM, Staff 1 (Administrator) acknowledged she expected a needle to be left at a residents bedside. On 1/21/20 at 8:55 AM, Staff 2 (DNS) stated she expected a needle to be disposed of in a sharps container and not left…
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 before2020-01-21 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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 determine if a resident's clinical condition necessitated catheterization for 1 of 1 sampled resident (#6) reviewed for urinary catheters. This placed residents at risk of unnecessary urinary catheterization. Findings include: Resident 6 was admitted to the facility in 6/2019 with diagnoses including chronic kidney disease. Observation on 1/15/20 at 7:47 AM, revealed Resident 6 had a urinary catheter bag and tubing. The 10/1/19 Significant Change of Condition MDS Assessment, revealed Resident 6 was incontinent and had no urinary catheter. Medical record review did not provide another diagnosis for the use of the urinary catheter. There was no documentation in the resident's health record which included the consideration of the risks and benefits of an indwelling (tube into bladder), other than incontinence catheter; the potential for removal of the catheter; and consideration of complications resulting from the use of an indwelling catheter. On 1/15/20 at 4:15 PM and 1/17/20 at 11:57 AM, Staff…
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 · D2020-01-21 · 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 record review and interview it was determined the facility failed to ensure a resident was free from receiving incorrect medication for 1 of 7 sampled residents (#208) reviewed for unnecessary medications. This placed residents at risk for unnecessary medications and side effects. Findings include: Resident 208 was admitted to the facility in 4/2018 with diagnoses including delusional disorders. The facility's unnamed summary of an incident on 12/24/18 during the overnight shift revealed Resident 208 was administered a PRN dose of Ativan (antianxiety medication). Resident 208 had no orders for PRN Ativan. Resident 208 had no adverse reaction to the dose of Ativan. Resident 208's 12/2018 Physician Orders revealed the resident had scheduled ativan every morning. Resident 208 had no PRN Ativan orders. In an interview on 1/16/20 at 12:33 PM Staff 1 (Administrator) and Staff 2 (DNS) stated the medication error occurred because staff mixed up Resident 208 with another resident. Staff 1 and Staff 2 stated they expected residents to receive the correct medications. The facility…
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 before2020-01-21 · 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, interview and record review it was determined the facility failed to provide adequate care and services related to catheter care for 1 of 1 sampled resident (#6) reviewed for urinary catheter care. This placed residents at risk for infection and displacement of the catheter. Findings include: Resident 6 was admitted to the facility in 6/2019 with diagnoses including hypertensive chronic kidney disease. The Significant Change of Condition MDS Assessment completed 10/1/19 indicated Resident 6 had no use of a urinary catheter. A 10/25/19 Urology note indicated Resident 6 had a catheter placed for incontinence. Resident 6 was observed to sit in her/his wheel chair and recliner chair with the catheter tubing resting on the floor under the wheel chair before entering the catheter bag on the following occasions: - 1/13/20 at 4:46 PM; - 1/15/20 at 7:47 AM; - 1/15/20 at 11:41 AM; - 1/15/20 at 12:35 PM; - 1/15/20 at 4:14 PM. On 1/15/20 at 4:15 PM, Staff 3 (RNCM) confirmed Resident 6's catheter tubing was on the floor. Staff 3 acknowledged the catheter tubing should never…
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.
“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
No federal fines in the current CMS record.
Part of a chain
This home belongs to CASCADIA HEALTHCARE — 46 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 | 5 of 5 | 3.0 | +2.0 vs chain |
| Health inspection | 4 of 5 | 2.8 | +1.2 vs chain |
| Staffing | 5 of 5 | 2.7 | +2.3 vs chain |
| Quality measures | 3 of 5 | 3.9 | -0.9 vs chain |
The other 45 homes this chain runs (chain average 3.0★, per CMS)
Showing 40 of 45; 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 / manager | Type | Role | Since |
|---|---|---|---|
| CASCADIA OREGON OPERATIONS LLC | Organization | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | since 04/01/2023 |
| CASCADIA HC GROUP LLC | Organization | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | since 06/05/2025 |
| CASCADIA HEALTHCARE LLC | Organization | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | since 04/01/2023 |
| CASCADIA HOLDCO LLC | Organization | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | since 06/05/2025 |
| HAMMOND, OWEN | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | since 04/01/2023 |
| LAFORTE, STEPHEN | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | since 06/05/2025 |
| NELSON, TIMOTHY | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | since 06/05/2025 |
| GRESHAM 3457 REALTY, LLC | Organization | 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | since 06/05/2025 |
| WHITE OAK HEALTHCARE FINANCE LLC | Organization | 5% OR GREATER SECURITY INTEREST | since 08/11/2022 |
| CASCADIA SERVICES LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/10/2025 |
| VELLODY, NITA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/26/2025 |
| WORKMAN, LESLIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/19/2024 |
CMS files one row per role, so the 23 rows in the source record cover these 12 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.
7 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 $433K 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
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 385133. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-27, 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 →
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