Hillsboro Health And Rehabilitation
1778 NE Cornell Road, Hillsboro, OR 97124 · For profit - Corporation · 78 certified beds · (503) 648-6621 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- 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 (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0602), cited Sep 2023
- 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
- 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) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 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 | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 4 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 held steady at 4 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 | 15.0% | 14.9% | 15.4% | typical |
| Long-stay residents who lose too much weight | 9.4% | 4.7% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.7% | 1.4% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.7% | 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 | 1.9% | 2.4% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 18.1% | 20.6% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 7.8% | 12.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.4% | 5.8% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 22.8% | 21.8% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.4% | 13.9% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.5% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 96.8% | 81.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 23.5% | 21.4% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 21.1% | 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.
61.5% 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 96 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 62.2% 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 45 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 0.33 therapist hours per resident per day in 2026Q1 — more than 56% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 22% 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 | 61.5%CMS range 52.6–68.9 | 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 | 10.4%CMS range 7.4–14.2 | 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 | 62.2% | 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 | 57.8% | 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 | 37.8% | 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 | 98.7% | 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 | 93.8% | 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 | 1.3% | 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 | 1.3% | 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 | 7.4%CMS range 4.3–11.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.82 | 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 78 beds and averages 58.0 residents a day — about 74% occupied, or roughly 20 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.67 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.58 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.21 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 4.22 hrs/resident/day on weekends vs 4.85 on weekdays — 13% thinner on weekends. RN hours go from 0.68 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 41% is about the same as the national median of 45%. 1 administrator has left in the past year.
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 10 most serious are shown; the remaining 17 are one tap away and print in full.
- Potential for harm · D2025-08-12 · tag F0609 — failed to report abuse allegations — isolatedTimely 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, the facility failed to report an allegation of abuse to the State Agency for 2 of 2 sampled residents (#s 6 and 10) reviewed for abuse. This placed residents at risk for abuse. Findings include:Resident 6 admitted 1/2025 with diagnoses including dementia.Resident 6's 6/9/25 MDS revealed Resident 6 had a BIMS of 5, which indicated a severe cognitive impairment.A 6/9/25 Sexual Capacity Evaluation indicated Resident 6 did not have sufficient memory and/or cognitive function to make the choice for sexual activity.Resident 10's 1/29/25 MDS revealed Resident 10 had a BIMS of 8, which indicated a moderate cognitive impairment.A 6/9/25 Sexual Capacity Evaluation indicated Resident 10 did not have sufficient memory and/or cognitive function to make the choice for sexual activity.On 8/11/25 at 1:04 PM, Staff 20 (CMA) stated she saw Resident 6 sitting on Resident 10's bed on 6/9/25. She stated Resident 10 was touching Resident 6's breasts and was offering Resident 6 money. She stated staff separated Resident 6 and Resident 10.On 8/11/25 at 1:07 PM,…
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 · D2025-08-12 · 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, the facility failed to investigate allegations of abuse for 2 of 2 sampled residents (#s 6 and 10) reviewed for abuse. This placed residents at risk for abuse. Findings include:Resident 6 admitted 1/2025 with diagnoses including dementia.Resident 6's 6/9/25 MDS revealed Resident 6 had a BIMS of 5, which indicated a severe cognitive impairment.A 6/9/25 Sexual Capacity Evaluation indicated Resident 6 did not have sufficient memory and/or cognitive function to make the choice for sexual activity.Resident 10's 1/29/25 MDS revealed Resident 10 had a BIMS of 8, which indicated a moderate cognitive impairment.A 6/9/25 Sexual Capacity Evaluation indicated Resident 10 did not have sufficient memory and/or cognitive function to make the choice for sexual activity.On 8/11/25 at 1:04 PM, Staff 20 (CMA) stated she saw Resident 6 sitting on Resident 10's bed on 6/9/25. She stated Resident 10 was touching Resident 6's breasts and was offering Resident 6 money. She stated staff separated Resident 6 and Resident 10.On 8/11/25 at 1:07 PM, Resident 10 stated…
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 · D2025-08-12 · 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 interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 sampled resident (#5) reviewed for accidents. This placed residents at risk for injury due to accidents. Findings include:Resident 5 admitted in 7/2025 with diagnoses including hemiplegia and hemiparesis following cerebral infarction (stroke) affecting left non-dominant side.Resident 5's 7/18/25 care plan indicated Device: Seat belt-gait belt from home and Mobility Device: Electric wheelchair, assist resident with seat belt.A 7/20/25 progress note indicated Resident 5 was found on the floor, stated she/he slid out of her wheelchair and called emergency from her/his personal cell phone. Resident 5 had a laceration on her/his leg and was bleeding. Resident 5 was taken to the hospital for evaluation.On 8/8/25 at 12:28 PM, Staff 12 stated Resident 5 slipped out of her/his wheelchair and onto the floor. He further stated he could not get Resident 5's seat belt around her/him because it was too small. He was unsure if use 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 · Dcited before2025-05-23 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to develop a resident centered care plan for 1 of 1 sampled resident (#1) reviewed for activities. This placed residents at risk for a lack of meaningful, purposeful and preferred activities and unmet psychosocial needs. Findings include: Resident 1 admitted to the facility in 12/2023 with diagnoses including dementia. The 3/1/25 Annual MDS assessed Resident 1 with a BIMS of three, which indicated severe cognitive impairment. The MDS Activity Preferences section indicated she/he found reading materials and the news somewhat important to her/him. Music, animals, going out in the fresh air and doing her/his favorite activities were very important. The 3/25/25 Activity Progress Note: Annual Review evaluation indicated Resident 1 was independent with activities and did not get out of bed. Resident 1 enjoyed The Daily Chronicle (flyer which provides reading, puzzles, coloring pages and other reading activities) and talking to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-23 · 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
Based on observation, interview and record review it was determined the facility failed to provide the necessary care and assistance to maintain good grooming and hygiene for 1 of 4 sampled resident (#43) reviewed for ADLs. This placed residents at risk for poor grooming. Findings include: Resident 43 was admitted to the facility in 3/2025 with diagnoses including nephrogenic diabetes insipidus (a medical disorder that occurs when your kidneys cannot properly balance bodily fluids) and ataxia (impaired muscle control that can affect walking, balance and the coordination of hand movements). A review of Resident 43's 5/3/25 admission MDS revealed she/he was cognitively intact and required supervision or touching assistance to complete personal hygiene tasks. Resident 43's care plan dated 4/28/25 revealed she/he received maximal/substantial assistance with showers on Sunday and Wednesday evenings and required supervision/touch assistance for grooming and personal hygiene. On 5/19/25 at 11:04 AM Resident 43 was observed to have a thick cluster of dark hairs growing from her/his chin.…
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 before2025-05-23 · 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 respond to a change of condition and provide respiratory interventions timely for 1 of 1 resident reviewed (# 41) for change of condition. This placed residents at risk for respiratory distress. Findings include: Resident 41 admitted to the facility in 2023 with diagnoses including chronic obstructive pulmonary disease (COPD), chronic kidney disease and atrial fibrillation. The facility undated Standing Orders for oxygen indicated the goal of supplemental oxygen was to maintain saturations above 89% for residents with COPD. The orders indicated oxygen may go up to 2 liters before the provider was to be urgently notified. The 10/30/23 Care Plan directed staff to monitor Resident 41 for difficulties breathing and signs or symptoms of acute respiratory insufficiency. A Facility Report Incident indicated at 7:00 AM on 12/16/24, Resident 41 was found to have oxygen saturations of 64%. Resident 41's oxygen saturations were checked an additional two more times which were below 70%. Staff 5 (CNA) informed Staff 9…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-23 · 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 conduct weekly skin observations and evaluations to identify pressure ulcers and administer treatments timely treatment for 1 of 3 sampled resident (#359) reviewed for pressure ulcers. This placed residents at risk for complications related to unavoidable skin breakdown and not receiving care to treat pressure ulcers in a timely manner. Findings include: Resident 359 was admitted to the facility in 3/2024 with diagnoses including Alzheimer's disease (a progressive disorder which primarily affects the brain and leads to cognitive decline) and diabetes mellitus. A review of Resident 359's 3/18/24 admission MDS revealed she/he had severe cognitive impairment, had pressure ulcers, was at risk for the development of additional pressure ulcers and was dependent on staff for bed mobility. The Pressure Ulcer/Injury CAA indicated the facility provided Resident 359 with a pressure relieving mattress for her/his bed to minimize the pressure on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-23 · 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 opioid medications for 1 of 6 sampled residents (#45) reviewed for medications. This placed residents at risk for complications related to narcotic medications. Findings include: Resident 45 was admitted in 3/2025 with diagnoses included alcoholic cirrhosis of the liver (severe liver disease) with ascites (abnormal build-up of fluid in the space between the organs and the lining of the abdomen). Resident 45's 4/17/25 physician order indicated the resident was to be administered two tablets of oxycodone (opioid pain medication) every four hours as needed for pain levels of eight to 10 out of 10. Resident 45's 5/2025 MAR indicated the resident was administered two tablets of oxycodone when her/his pain levels were less than eight as follows: -5/1: for pain levels of 6 and 7. -5/2: for pain levels of 5 and 6. -5/3: for pain levels of 4 and 5. -5/4: for pain levels of 5 and 6. -5/5: for a pain level of 6. -5/8: for pain levels of 4 and 5. -5/7: for a pain level of 7. -5/8: 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 · E2024-02-09 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined the facility failed to ensure a homelike environment for 1 of 1 facility reviewed for homelike environment. This placed residents at risk for adverse health conditions and an unclean environment. Findings include: Observations of the facility's general environment and residents' rooms from 2/5/24 through 2/9/24 identified the following issues: -Dirty floor vents inside the beauty shop, outside the beauty shop, outside of rooms [ROOM NUMBERS]. -Four dime sized holes on the wall next to the timeclock. -One brown water stained ceiling tile in the main dining area near the kitchen entrance, two brown water stained ceiling tiles outside room [ROOM NUMBER]. -Gouged/damaged walls with paint missing behind resident beds in Rooms 109, 114-1, 114-2, 208-2, 312 and 315. -Lights not working on Hall 100 outside rooms [ROOM NUMBERS], Hall 200 outside rooms [ROOM NUMBERS], and Hall 300 outside the therapy room. -room [ROOM NUMBER]'s door had missing pieces of wood leaving…
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 before2024-02-09 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide 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 observation, interview and record review it was determined the facility failed to ensure physician orders were followed for 4 of 8 sampled residents (#s 32, 34, 36 and 42) reviewed for choices, care plans and medications. This placed residents at risk for unmet needs. Findings include: 1. Resident 36 was admitted to the facility in 7/2023 with diagnoses including type 2 diabetes mellitus, GERD (acid reflux), hypertension (high blood pressure) and chronic congestive heart failure (heart condition which can result in rapid weight gain from fluid build-up). a. Resident 36's 1/17/24 Quarterly MDS indicated the resident was cognitively intact. On 2/5/24 at 9:24 AM Resident 36 stated she/he received her/his Rybelsus (diabetic medication) late everyday. Resident 36 stated the medication was supposed to be taken before breakfast and staff brought it with the rest of her/his medications after breakfast. Resident 36's 2/2024 Physician Orders included Rybelsus 7 mg everyday for diabetes mellitus 2. The order included the following instructions: - Must be given 30 minutes before first…
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 · Ecited before2024-02-09 · tag F0732 — patternPost nurse staffing information every day.
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 the Direct Care Staff Daily Reports were completed for 21 out of 67 sampled days reviewed for staffing. This placed residents at risk for incorrect staffing information. Findings include: A review of the Direct Care Staff Daily Reports dated 12/1/23 through 2/5/24 revealed 21 out of 67 days the Resident census, CNA and/or RN hours were blank for one or more shifts for the following days: -12/1/23 -12/2/23 -12/5/23 -12/6/23 -12/7/23 -12/8/23 -12/9/23 -12/10/23 -12/12/23 -12/14/23 -12/15/23 -12/16/23 -12/19/23 -12/20/23 -12/21/23 -12/22/23 -12/23/23 -12/24/23 -1/6/24 -2/1/24 -2/2/24 On 2/8/24 at 10:59 AM Staff 6 (Activities Director/Staffing Coordinator) acknowledged the incomplete Resident census and CNA and/or RN hours for the days identified.
- Potential for harm · E2024-02-09 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
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 medication administration error rate of less than 5%. There were seven errors in 29 opportunities resulting in a 24.14% error rate. This placed residents at risk for reduced medication efficacy and adverse medication side effects. Findings include: 1. Resident 36 was admitted to the facility in 7/2023 with diagnoses including type 2 diabetes mellitus. Resident 36's 2/2024 Physician Orders included: - Rybelsus (diabetic medication) 7 mg everyday for type 2 diabetes mellitus, must be given 30 minutes before first food/beverage/other medications with plain water. - omeprazole (stomach acid reducer) oral capsule delayed release, 20 mg two times a day before meals. - Humulin R (short-acting insulin), inject three units before meals. On 2/6/24 at 7:58 AM Resident 36 was observed with her/his breakfast meal partially consumed. Resident 36 stated she/he did not receive any of her/his medications yet. On 2/6/24 from 8:09 AM until 8:34 AM Staff 19 (LPN) was observed for Resident 36's 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 · E2024-02-09 · 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
3. On 2/7/24 at 12:05 PM Staff 16 (Cook) was observed working at the kitchen's steam table preparing and plating food for the lunch meal. She was observed touching the food with utensils and her gloved hands. She then stepped away from the steam table to retrieve a salad from the refrigerator adjacent to the food preparation area. She was observed to open the refrigerator with her gloved hand, retrieve a salad that was covered in cling film and close the refrigerator door with her gloved hand. Without changing her gloves or completing hand hygiene, she returned to the steam table, removed the cling film from the prepared salad, placed it on a tray for delivery to a resident and continued to handle food using utensils and her gloved hands. On 2/7/24 at 12:07 PM when asked when it was appropriate change her gloves, Staff 16 pointed to a stack of gloves on tray table and stated, I do it all the time during tray line. That's why I keep the stack of gloves right there. When asked why she did not change her gloves after touching the refrigerator door handle, she stated, I should have…
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 · D2024-02-09 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
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 assessed for safe self-administration of medications prior to leaving medications unattended at the resident's bedside for 1 of 5 sampled residents (#36) reviewed for medications. This placed residents at risk for unsafe medication administration. Findings include: The facility's 9/2017 Self-Administration of Medication Policy & Procedure indicated a self-administration medication evaluation was completed before the resident was able to self-administer medications. If a resident was determined to safely self-administer medications, the nurse obtained a physician order for self-administration of the specific medication, a self-administration care plan was initiated and proper safety mechanisms were initiated to ensure medications were safely stored. Resident 36 was admitted to the facility in 7/2023 with diagnoses including diabetes mellitus type 2. Resident 36's 1/17/24 Quarterly MDS indicated the resident was cognitively intact and received medication for diabetes…
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 · D2024-02-09 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review it was determined the facility failed to ensure a written summary of a baseline care plan was reviewed and provided to residents within 48 hours of admission for 1 of 2 sampled residents (#36) reviewed for care planning. This placed residents at risk for being uninformed about their plan of care. Findings include: Resident 36 was admitted to the facility in 7/2023 with diagnoses including diabetes mellitus type 2. Resident 36's 1/17/24 Quarterly MDS indicated the resident was cognitively intact. On 2/5/24 at 9:24 AM Resident 36 was unable to recall if the facility reviewed and provided her/him with a baseline care plan. Resident 36's health record revealed no evidence a baseline care plan was reviewed and provided to the resident within 48 hours. On 2/8/24 at 1:40 PM Staff 2 (DNS) and Staff 20 (Divisional Director of Clinical Operations) were notified of the findings of this investigation. Staff 2 stated the facility was not consistent with review and provision of baseline care plans within 48 hours as required.
- Potential for harm · D2024-02-09 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 care plans were revised to accurately reflect the needs of residents for 3 of 8 sampled residents (#s 2, 36 and 42) reviewed for care plans, medications and accidents. This placed residents at risk for unmet needs. Findings include: The facility's 5/2023 Care Directive Policy & Procedure specified the ISP (individual service plan) was part of the care planning process and updates and revisions were completed as appropriate. 1. Resident 36 was admitted to the facility in 7/2023 with diagnoses including type 2 diabetes mellitus. Resident 36's current Care Plan indicated the following: - Monitor adverse side effects and/or toxic symptoms of trazodone (antidepressant). Resident 36's health record indicated the trazodone order was discontinued on 10/22/23. On 2/8/24 at 1:36 PM Staff 2 (DNS) and Staff 20 (Divisional Director of Clinical Operations) were notified of the findings of this investigation and acknowledged Resident 36's care plan was not updated to reflect the resident's current…
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 · D2024-02-09 · 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 obtain and provide routine medications for 1 of 5 sampled residents (#36) reviewed for medications. This placed residents at risk for not receiving prescribed medications. Findings include: Resident 36 was admitted to the facility in 7/2023 with diagnoses including diabetes mellitus type 2. Resident 36's 12/2/23 Physician Orders included the following: - calcitonin nasal solution 200 unit/ACT, one spray alternating nostrils one time a day for osteoporosis (bone brittleness and weakness). Resident 36's 12/2023 MAR revealed 00 was marked on the following 21 days: - 12/5/23, 12/6/23, 12/7/23, 12/8/23, 12/9/23, 12/10/23, 12/11/23, 12/15/23, 12/16/23, 12/17/23, 12/18/23, 12/19/23, 12/20/23, 12/21/23, 12/25/23, 12/28/23, 12/29/23, 12/30/23 and 12/31/23. Resident 36's 1/2024 Physician Orders included the following: - calcitonin nasal solution 200 unit/ACT, one spray alternating nostrils one time a day for osteoporosis. Resident 36's 1/2024 MAR revealed 00 was marked on the following five days: - 1/1/24, 1/2/24,…
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 · D2024-02-09 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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 on pharmacist recommendations for 1 of 5 sampled residents (#36) reviewed for medications. This placed residents at risk for medication errors. Findings include: The facility's 3/2019 Medication Regimen Review (MRR) Policy & Procedure specified the procedure as follows: - A pharmacist completes the monthly MRR, the pharmacist sends an email report of any irregularities and the facility and attending physician respond to the recommendations within two weeks. Resident 36 was admitted to the facility in 7/2023 with diagnoses including diabetes mellitus type 2. Resident 36's 9/16/23 Consultant Pharmacist MRR revealed the following recommendation: - Resident has an order for calcitonin nasal spray. Be sure to add right alternating left nostril [every day]. The MAR [indicates] we are giving it into the right nostril every day. Resident 36's 9/2023 MAR revealed calcitonin spray was not administered in alternating nostrils and the Consultant Pharmacist MRR recommendation was not implemented. 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 · Dcited before2024-02-09 · 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 ensure antibiotics were administered as ordered for 1 of 5 sampled residents (#36) reviewed for medications. This placed residents at risk for receiving unnecessary medications, experiencing adverse medication effects and developing antibiotic resistance. Findings include: The CDC Core Elements of Antibiotic Stewardship (https://www.cdc.gov/antibiotic-use/core-elements/nursing-homes.html) dated 8/2021 indicated Antibiotics are among the most frequently prescribed medications in nursing homes, with up to 70% of residents in a nursing home receiving one or more courses of systemic antibiotics when followed over a year. Harms from antibiotic overuse are significant for the frail and older adults receiving care in nursing homes. These harms include risk of serious diarrheal infections, increased adverse drug events and drug interactions, and colonization and/or infection with antibiotic-resistant organisms. Resident 36 was admitted to the facility in 7/2023 with diagnoses including major depressive disorder.…
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 · D2024-02-09 · 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
Based on interview and record review it was determined the facility failed to ensure residents were comprehensively assessed for the use of psychotropic medications and failed to ensure GDR (gradual dose reduction) was attempted for 1 of 5 sampled residents (# 36) reviewed for medications. This placed residents at risk for receiving unnecessary medications. Findings include: Resident 36 was admitted to the facility in 7/2023 with diagnoses including major depressive disorder. Resident 36's 7/24/23 admission MDS revealed the resident used an antidepressant medication to treat her/his depression, had no behaviors and scored 0 on the PHQ-9 assessment (used to detect the presence and severity of depression; high score indicates symptoms of depression). The MDS Psychotropic Drug Use CAA indicated the facility worked in concert with the resident's physician and the pharmacy consultant to attempt a GDR of the antidepressant medications when appropriate. Resident 36's 1/17/24 Quarterly MDS revealed the resident used an antidepressant, had no behaviors and scored 0 on the PHQ-9 assessment.…
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 · D2023-09-05 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review it was determined the facility failed to ensure resident narcotic medications were not misappropriated for 1 of 1 resident (# 9) reviewed for anti-anxiety medications. This placed residents at risk for loss of property. Findings include: Resident 9 was admitted to the facility in 2017 with diagnoses including Alzheimer's and Heart Disease. Resident 2/17/22 admission MDS identified Resident 9 with severe cognitive impairment. Resident 9 10/20/22 Care Plan revised on 5/15/22 indicated the resident used anti-anxiety medications Lorazepam, related to comfort measures for end-of-life care. A 5/12/23 Facility Risk Management Report identified a 24 ml bottle of liquid Lorazepam used to treat Resident 9 for end-of-life care went missing on 5/7/23 at 1:00 AM. A facility wide comprehensive medication reconciliation was conducted by the facility on all narcotic medications from 5/7/23 to 5/9/23. According to the facility report, care staff and management were unable to locate the missing bottle of Lorazepam. On 8/30/23 at 2:50 PM Staff 10 (LPN) indicated…
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 before2022-11-04 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide 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 ensure physician orders were followed for 2 of 5 sampled residents (#s 29 and 34) reviewed for unnecessary medications. This placed residents at risk for adverse medication consequences. Findings include: 1. Resident 34 was admitted to the facility in 3/2022 with diagnoses including heart failure and hypertension. a. A 3/24/22 physician order indicated Resident 34 was prescribed amlodipine (a medication used to treat high blood pressure and heart conditions) one time a day at bedtime; hold for systolic blood pressure (SBP) less than 110 or heart rate (HR) less than 60. A review of Resident 34's 9/2022 and 10/2022 MARs indicated the resident received amlodipine on all days during both months; however, there was no evidence in Resident 34's clinical record staff were monitoring SBP or HR prior to administering the resident's amlodipine except on the following days: 9/1, 9/2, 9/3, 9/4, 9/5, 9/6, 9/7, 9/8, 9/9, 9/10, 10/1, 10/3, 10/10, 10/22 and 10/31. Resident 34's 10/2022 MAR indicated staff monitored SBP…
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 · D2022-11-04 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 resident assessments were accurate for 1 of 1 sampled resident (#26) reviewed for contractures. This placed residents at risk for unmet needs. Findings include: Resident 26 was admitted to the facility in 5/2020 with diagnoses including dementia. During multiple random observations from 10/31/22 through 11/4/22 between the hours of 9:00 AM and 4:00 PM, Resident 26 was observed with contractures of all fingers on both hands and both wrists that curved into a C-shape. A 5/8/20 Admission-readmission Nursing Evaluation revealed Resident 26 had contractures of both hands upon admission. Resident 26's MDS assessments indicated the resident had no upper extremity contractures on the following annual and quarterly assessments: 11/16/21, 2/16/22, 5/17/22 and 8/17/22. On 11/2/22 at 12:19 PM Staff 11 (LPN Care Manager) stated Resident 26 had contractures of her/his fingers and wrists on both hands which were present upon admission. On 11/2/22 at 2:20 PM Staff 10 (MDS Coordinator) confirmed all 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 · Dcited before2022-11-04 · 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 interview and record review it was determined the facility failed to ensure comprehensive, person-centered care plans for vision were developed for 1 of 1 sampled resident (#29) reviewed for vision and hearing. This placed residents at risk for unmet care needs. Findings include: Resident 29 was admitted to the facility in 12/2021 with diagnoses including multiple sclerosis (an autoimmune disease that impacts the brain, spinal cord, and optic nerves), diabetic retinopathy (a complication of diabetes that affects the eyes), and cataract. The Vision CAA from Resident 29's 12/2021 admission MDS noted Resident 29 had a visual field deficit and decreased visual acuity. The CAA further indicated the need for a care plan in order to minimize risks related to her/his impaired visual function and for staff to approach from the left side or the front if possible. A review of Resident 29's comprehensive care plan (last revised 10/20/22) revealed no problem statements, goals or interventions related to vision. On 11/3/22 at 11:42 AM Staff 11 (LPN Care Manager) confirmed a vision 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 · D2022-11-04 · 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 interview and record review it was determined the facility failed to ensure residents received restorative services for 1 of 1 sampled resident (#34) reviewed for restorative services. This placed residents at risk for decreased mobility. Findings include: Resident 34 was admitted to the facility in 3/2022 with diagnoses including injuries from a motor vehicle accident. Resident 34's 10/1/22 MDS indicated she/he required two people for assistance with transfers, toileting, personal hygiene and Resident 34 did not walk. Resident 34's 9/26/22 Restorative Program indicated the resident was to receive restorative services two to three times a week to maintain bilateral lower extremity ROM and strength. Resident 34's program consisted of the following: -transfers using a sliding board; -active ROM of both legs; -hip exercises; -stretching exercises; -passive ROM to both ankles. Resident 34's 10/2022 restorative treatment record indicated the resident received restorative services as follows: -10/10 through 10/16: Resident 34 received restorative treatment one time; -10/24…
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 · D2022-11-04 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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 records were complete and accurate for 2 of 5 sampled residents (#s 29 and 34) reviewed for unnecessary medications. This placed residents at risk for inaccurate clinical records. Findings include: 1. Resident 34 was admitted to the facility in 3/2022 with diagnoses including heart failure and hypertension. A 3/24/22 physician order indicated Resident 34 was prescribed Ramelteon one time a day. A 3/25/22 Notice of Insurance Non-Payment indicated Ramelteon was not covered by insurance and a new order was provided to begin melatonin at bedtime instead. A review of Resident 34's 9/2022 and 10/2022 MARs revealed most dates were marked OO indicating Ramelteon was on order from the pharmacy. On 9/1, 9/11, 9/18, 9/24, 9/28 10/1, and 10/22 the MARs were marked with a check mark indicating Ramelteon was given. On 11/3/22 at 1:17 PM Staff 2 (DNS) stated the facility never received Ramelteon because it was not covered by insurance and it was replaced with an order for melatonin. Staff 2 stated nursing…
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.
- No harm found · Ccited before2025-05-23 · tag F0732 — widespreadPost nurse staffing information every day.
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 the Direct Care Staff Daily Report (DCSDR) postings were accurate for 5 of 7 days reviewed for RN staffing. This placed residents and visitors at risk for inaccurate staffing information. Findings include: A review of the facility's DCSDRs on 5/1/25, 5/5/25, 5/6/25, 5/7/25, 5/12/25, 5/13/25 and 5/14/25 revealed the postings inaccurately reflected the facility's RN coverage on the following days: -5/5, 5/6, 5/12, 5/13 and 5/14. On 5/22/25 at 12:15 PM, Staff 14 (Staffing Coordinator) confirmed the facility's DCSDRs inaccurately reflected RN coverage on 5/5/25, 5/6/25, 5/12/25, 5/13/25 and 5/14/25.
“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 EVERGREEN HEALTHCARE GROUP — 44 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 | 4 of 5 | 2.5 | +1.5 vs chain |
| Health inspection | 4 of 5 | 2.4 | +1.6 vs chain |
| Staffing | 4 of 5 | 3.3 | +0.7 vs chain |
| Quality measures | 4 of 5 | 3.0 | +1.0 vs chain |
The other 43 homes this chain runs (chain average 2.5★, per CMS)
Showing 40 of 43; 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 |
|---|---|---|---|
| PACIFIC NORTHWEST SNF OPERATIONS HOLDINGS (OR) LLC | Organization | DIRECT OWNERSHIP INTEREST | since 08/31/2023 |
| CH PACIFIC NORTHWEST HOLDINGS LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 08/31/2023 |
| PACIFIC NORTHWEST SNF OPERATIONS HOLDINGS LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 08/31/2023 |
| WITZCORP GLOBAL LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 08/31/2023 |
| HERZKA, YISROEL | Individual | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 08/31/2023 |
| YENOWITZ, YITZCHOK | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNF | since 08/31/2023 |
| CEPEDA, MYLENE | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/31/2023 |
| ODENTHAL, JASON | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/31/2023 |
| COUVE FINANCIAL SERVICES LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/31/2023 |
| COUVE HEALTHCARE CONSULTING LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/21/2025 |
| HILLSBORO SNF OPERATIONS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/31/2023 |
| OREGON SNF CONSULTING LLC (DE) | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/21/2025 |
| PACIFIC NORTHWEST OPCO MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/31/2023 |
| HILLMAN, JONATHAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/31/2023 |
| LARSON, DAVID | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/31/2023 |
| SPIELMAN, SHIMON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/31/2023 |
CMS files one row per role, so the 35 rows in the source record cover these 16 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.
9 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 $173K 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 385217. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-23, 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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