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Hood River Post Acute

729 Henderson Road, Hood River, OR 97031 · For profit - Limited Liability company · 100 certified beds · (541) 386-2688 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jun 2024Resident-funds citation (F0567)1 immediate-jeopardy citation$38,636 in federal fines
Insights

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

In its favor
  • 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
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2024
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0567)
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $38,636 in federal fines (most recent 2024-09-27)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

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

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

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
Ohsu0.7 mi
1410 May St · (541) 386-1399 · Call to confirm hours
Pharmacy
Rite Aid0.8 mi
2049 Cascade Ave · (541) 387-2428 · Call to confirm hours
Grocery
Safeway0.7 mi
2249 Cascade Ave · (541) 386-1841 · Call to confirm hours
Park
1711 Heritage Loop · Typically dawn to dusk
Place of worship
2168 Belmont Dr · (541) 386-2604

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 5 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 5 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 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased14.7%14.9%15.4%typical
Long-stay residents who lose too much weight0.5%4.7%5.4%better
Long-stay residents with a catheter left in their bladder1.2%1.4%0.9%worse
Long-stay residents with a urinary tract infection1.0%2.0%2.0%better
Long-stay residents with depressive symptoms7.3%4.9%6.5%worse
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury4.0%2.4%3.3%worse
Long-stay residents whose ability to walk worsened9.1%20.6%16.1%better
Long-stay residents on antianxiety or hypnotic medication17.0%12.4%18.9%better
Long-stay residents given the seasonal flu vaccine95.3%95.2%95.3%typical
Long-stay residents with pressure ulcers4.2%5.8%4.7%better
Long-stay residents with worsening bladder/bowel control28.2%21.8%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table30.5%13.9%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.4%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine68.0%81.2%79.4%worse
Short-stay residents rehospitalized after admission19.4%21.4%22.6%better
Short-stay residents with an outpatient ER visit12.8%16.1%12.0%typical
Long-stay hospitalizations per 1,000 resident days0.811.481.67better
Long-stay outpatient ER visits per 1,000 resident days2.012.351.80worse

§ 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.

71.6% 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 90 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

71.6%U.S. median 51.5%
Got home and stayed home
8.8%U.S. median 10.7%
Went back to hospital
66.3%U.S. median 56.6%
Met the expected recovery
0.30U.S. median 0.31
Therapy hours / resident / day
0.09hours / resident / day
Physical therapy
0.16hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 66.3% 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 101 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 0.30 therapist hours per resident per day in 2026Q1 — more than 47% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 20% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF71.6%CMS range 61.9–79.051.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF8.8%CMS range 5.3–13.210.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge66.3%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge50.5%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge57.4%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified99.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 discharge100.0%98.7%Oct 2024–Sep 2025CMS 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 stay0.8%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.8%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.5%CMS range 3.9–12.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.831.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.39
RN hours/ resident / day
1.24
LPN hours/ resident / day
3.31
Aide hours/ resident / day
4.94
Total nurse hours/ resident / day
0.32
RN hoursweekends
48.2%
Total nursing turnover
62.5%
RN turnover

How full it usually is: this home is certified for 100 beds and averages 71.1 residents a day — about 71% occupied, or roughly 29 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 4.94 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.39 is below the 0.55-hour RN benchmark and nurse-aide staffing of 3.31 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 4.27 hrs/resident/day on weekends vs 5.21 on weekdays — 18% thinner on weekends. RN hours go from 0.43 to 0.32 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 48% 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

8
deficiencies at the latest standard inspection (2026-03-13)
14
at the previous standard inspection (2024-09-27)

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.

ABCDEFGHIJKL

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

29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.

  • Immediate jeopardy · L2024-09-27 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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 store foods at appropriate temperatures for 1 of 3 kitchen refrigerators reviewed for food safety. The facility's failure was determined to be an immediate jeopardy situation because raw meat stored outside of an acceptable temperature was planned to be used for an upcoming meal. Findings include: According to the U.S. Food and Drug Administration's Food Code 2022, (Chapter 3, Section 501.13), food shall be thawed under refrigeration that maintains the food temperature at 41 degrees F or less. Chapter 3, Section 501.13 goes on to say, improper thawing provides an opportunity for surviving bacteria to grow to harmful numbers and/or produce toxins. On 9/23/24 at 10:24 AM an initial inspection of the kitchen was performed. During this inspection an internal refrigerator thermometer read 45 degrees F. This refrigerator contained uncooked meat thawing, bacon, various salad dressings, cooked ham, cooked pulled pork, salami, pasteurized eggs, pasteurized cheeses and butter. On 9/25/24 at 11:20 AM…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-03-13 · tag F0605 — failed to not use drugs as a restraint — pattern
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    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 using psychotropic medications received gradual dose reductions for 4 of 5 sampled residents (#s 4, 8, 9, and 71) reviewed for medications. This placed residents at risk for unnecessary uses of psychotropic medications. Findings include:1. Resident 8 was admitted to the facility in 6/2024 with diagnoses including paranoid schizophrenia (mental health condition) and anxiety disorder (mental health condition). Resident 8's 12/13/25 Quarterly MDS indicated the resident received antipsychotic and antianxiety medications with no Gradual Dose Reduction (GDR) attempted and no documentation existed from the physician indicating a GDR was clinically contraindicated. Resident 8's 3/2026 Physician Orders included the following: - buspirone HCl Oral Tablet (antianxiety medication) 10 mg by mouth two times a day and 15 mg by mouth at bedtime for anxiety, active since 11/19/24. - perphenazine Oral Tablet 4 MG (antipsychotic medication) 4 mg by mouth two times a day, active since 6/4/24 Resident 8'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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-13 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to assist residents to formulate an advanced directive for 2 of 2 sample residents (#s 10 and 14) reviewed for advance directives. This placed residents at risk for healthcare decisions to be in conflict with resident wishes. Findings include:1. Resident 10 was admitted to the facility in 2/2026 with diagnoses including hypertension (high blood pressure).A care plan dated 2/5/226 indicated Resident 10 was a full code, her/his advanced directive would be honored, and her/his advanced directive would be in the medical record at all times.A review of Resident 10's medical record revealed no evidence of an advanced directive.On 3/10/26 at 1:13 PM, Staff 2 (DNS) stated Resident 14 did not have an advanced directive and education was initiated regarding the difference between an advanced directive and a POLST (Physician Order for Life Sustaining treatment). Staff 2 stated the expectation was for the RCM or the Social Service Director to ensure if a resident has an advanced directive, it was obtained and scanned…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-13 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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 privacy was maintained when care was provided for 1 of 3 sampled resident (#11) reviewed for dignity. This placed residents at risk for a lack of privacy during care. Findings involved:The facility's Resident Rights Policy from 8/2019 revealed:-Employees shall treat all residents with kindness, respect, and dignity. Federal and states laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to privacy and confidentiality.Resident 11 was admitted to the facility in 2/2026 with diagnoses including cerebral infarction (blood flow blockage of a section of the brain which often results in death of brain cells), tracheostomy (surgical airway opening to facilitate breathing), and locked-in state (full consciousness but an inability to move or speak).A 2/18/26 admission MDS indicated Resident 11 to be in a comatose state with an inability to communicate.A 3/2/26 physician order included Resident 11's tracheostomy to be suctioned every six…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-13 · tag F0627 — isolated
    Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/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 ensure a safe discharge for 1 of 4 sampled residents (#82) reviewed for discharge. This placed residents at risk for lack of medical services. Findings include: Resident 82 was admitted to the facility in 9/2025 with diagnoses including seizures and anxiety.A physician order from 9/1/25 included 200 mg of lacosamide (antiseizure medication) to be administered twice a day for seizures.A physician order from 9/1/25 included 1 mg of clonazepam (antianxiety medication) to be administer twice a day for anxiety.Review of progress notes revealed Resident 82 transitioned home to an assisted living facility on 9/15/25. This note reports Resident 82 was provided his/her medications upon discharge.Review of Controlled Substance Log records from 9/2025 revealed Resident 82 had 33 tablets of lacosamide and 24 tablets of clonazepam which remained in the facility until they were disposed of on 11/9/25. Records showed the medications were not provided to Resident 82 upon discharge.On 3/10/26 at 2:31 PM 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 it was determined the facility failed to thoroughly investigate falls for 1 of 2 sampled residents (#83) reviewed for accidents. This placed residents at risk for further falls. Findings include:Resident 83 was admitted to the facility in 3/2025 with diagnoses includine Alzhimer's Disease and insomnia.A public complaint was made on 12/10/25 which alleged the facility failed to have intervention in place to mitigate Resident 83's falls.A 4/3/25 facility investigation indicated on 3/21/25 Resident 83 was found on the floor in her/his room. The investigation did not include an analysis of the root cause of the fall, or whether care planned interventions were effective, or if any additional interventions were put in place.A 4/3/25 facility investigation indicated on 3/23/25 Resident 83 was observed self ambulating in the hall near the nurse's station and Resident 83 was observed to fall.A 4/3/25 facility investigation indicated on 3/26/25 Resident 83 was found on the floor in her/his room. The investigation did not include an analysis of the root…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-13 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide 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 ensure residents received care and services related to the use of an indwelling catheter for 1 of 2 sampled residents (#56) reviewed for catheter care. This placed residents at risk for catheter care complications. Findings include: The facility's 9/1/24 policy and procedure related to indwelling catheters indicates care of residents' catheters includes monitoring for signs of complications.Resident 56 was admitted to the facility in 9/2025 with a diagnosis of acute and chronic respiratory failure with hypoxia (a potentially life-threatening condition where the lungs cannot adequately oxygenate the blood).Resident 56's health record revealed she/he was her/his own representative and was cognitively intact.A review of Resident 56's 9/24/25 admission and 12/25/25 Quarterly MDS assessments revealed she/he had an indwelling suprapubic catheter.Resident 56's 10/1/25 Care Plan indicated the facility was to follow up with urology consults as ordered.A progress note written by Staff 5 (Attending…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-13 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    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 maintain healthy parameters of nutritional status for 1 of 2 sample residents (#10) reviewed for nutrition. This placed residents at risk for impaired nutrition. Findings include:Resident 10 was admitted to the facility in 2/2026 with diagnoses including a Stage 3 Pressure Ulcer (a deep, full-thickness skin wound, often appearing as a crater, where the skin has broken down completely, exposing the fatty subcutaneous tissue) to her/his sacral region and left heel and moderate protein-calorie malnutrition.A 2/5/26 care plan indicated Resident 10 was at risk for nutritional imbalance due to a diagnosis of malnutrition.A review of Resident 10's weights revealed the following:-2/11/26 200 lbs-2/17/26 190 lbs-3/5/26 179.8 lbsA review of the 2/4/26 Skin Issues Evaluations revealed Resident 10 had a Stage 3 Pressure Ulcer on her/his left ankle and sacrum at admission.A 2/12/26 Nutrition at Risk Evaluation revealed Resident 10 was started on a protein supplement twice a day due to wounds.A 2/13/26…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-13 · tag F0880 — failed to prevent and control infections — isolated
    Provide 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 ensure precautions were in place for 1 of 6 sampled hallways (400 hall) reviewed for enhanced barrier precautions. This placed the residents at risk of acquiring an infection. Findings include:CDC's 6/2021 Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities instructed EBP were recommended for residents with indwelling medical devices, regardless of multidrug-resistant organism colonization status. Resident 55 was admitted to the facility in 2/2026 with diagnoses including gastrostomy status (a tube placed directly into the stomach through a small opening in the belly used for administering nutrition, fluids, and medications).Resident 55's 2/10/26 admission orders included an order for enhanced barrier precautions (EBP) (protective measures taken by nursing home staff for residents with specific germs or medical devices).On 3/9/26 and 3/10/26 between the hours of 8:37 AM and 3:38 PM no EBP signage or PPE was observed inside or outside Resident 55's room.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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-09-27 · tag F0575 — pattern
    Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview it was determined the facility failed to ensure contact information for pertinent State agencies and the required Long Term Care Ombudsman (LTCO) poster were accessible to residents for 1 of 2 units observed for required postings. This placed residents at risk for lack of information on how to file a complaint or how to report concerns. Findings include: On 9/23/24 at 11:00 AM the required postings to indicate how residents can contact the State Survey Agency, the State licensure office, adult protective services and LTCO were observed in a hallway outside of the facility's locked enhanced care unit (ECU). Neither posting was observed inside the ECU. On 9/25/24 at 3:30 PM Resident 1 stated she/he had no idea where to access the contact information for pertinent State agencies or the LTCO and she/he was interested to know this information. Resident 1 stated she/he was unable to leave the ECU without a staff escort. On 9/25/24 at 10:55 AM Staff 1 (Administrator) acknowledged the findings of this investigation and confirmed ECU residents could not…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-09-27 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview it was determined the facility failed to ensure sanitary laundry services were provided for 2 of 6 halls reviewed for infection control. This placed residents at risk for cross contamination. Findings include: On 9/24/24 at 12:57 PM and at 1:10 PM Staff 20 (Laundry Services) was observed to deliver clean resident clothing throughout the 400 and 500 Halls and used a small uncovered laundry cart. The laundry cart was left unattended while Staff 20 delivered resident clothing from room to room. On 9/27/24 at 10:02 AM Staff 1 (Administrator) acknowledged that clean resident clothing should be covered while being delivered.

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · D2024-09-27 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    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 a consent was obtained prior to administering antidepressant medications to residents for 1 of 5 sampled residents (#21) reviewed for unnecessary medications. This placed residents at risk for being uninformed about their medications. Findings include: Resident 21 was admitted to the facility in 8/2023 with diagnoses including fracture and dementia. Resident 21's 8/25/23 Physician Order indicated the resident was prescribed mirtazapine (antidepressant) for major depressive disorder. Resident 21's 8/2023 through 9/2024 MARs revealed the resident received mirtazapine daily. Review of Resident 21's health record revealed no documentation to indicate the resident was informed in advance of the risks and benefits of mirtazapine. On 9/25/24 at 10:57 AM Staff 2 (DNS) and Staff 3 (Regional Nurse Consultant) reviewed Resident 21's health record, acknowledged there was no documentation to indicate the resident was informed of the risks and benefits of mirtazapine and confirmed a consent was not obtained from…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-27 · tag F0554 — isolated
    Allow 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 interview and record review it was determined the facility failed to ensure a safe system for a resident's self-administration of medication for 1 of 2 sampled residents (#6) reviewed for care planning. This placed residents at risk for adverse medication reactions. Findings include: Resident 6 admitted to the facility in 2022 with a diagnosis of multiple sclerosis. An 6/25/24 quarterly MDS revealed Resident 6 was cognitively intact. A 3/10/22 Self-Administration of Medication form revealed Resident 6 was assessed to be capable of self-administration of multiple medications. The form also indicated Resident was 6 was not to be left unattended while medication was being administered. A 4/1/24 Self-Administration of Medication form revealed Resident 6 was assessed to be capable of self-administration of Ventolin (respiratory medication) only. On 9/23/24 at 12:56 PM Staff 18 (RN) was observed to leave four unidentified medications at Resident 6's bedside and then left the room. When questioned Staff 18 stated she believed Resident 6 had a medication administration 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-27 · tag F0557 — isolated
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    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 allowed to retain personal possessions for 1 of 1 sampled resident (#9) reviewed for choices. This placed residents at risk for diminished quality of life. Findings include: Resident 9 was admitted to the facility in 7/2024 with diagnoses including Schizoaffective disorder (a mental health condition marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression and mania). Resident 9's 8/6/24 admission MDS indicated the resident was cognitively intact and did not exhibit any mood symptoms or behaviors. The MDS also indicated it was very important to the resident to take care of her/his personal belongings. On 9/23/24 at 12:15 PM Resident 9 was observed in her/his wheelchair in the dining room. Resident 9 stated she/he wanted to speak with the State Surveyor but wanted Witness 1 (Family Member) to be present for the conversation via her/his cell phone. Resident 9 stated she/he would check out her/his cell…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-27 · tag F0567 — failed to protect residents' money held by the home — isolated
    Honor the resident's right to manage his or her financial affairs.
    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 had access to their personal funds on an ongoing basis for 2 of 2 sampled residents (#s 1 and 9). This placed residents at risk for lack of access to personal funds. Findings include: 1. Resident 1 was admitted to the facility in 10/2017 with diagnoses including borderline personality disorder (a mental disorder characterized by unstable moods, behavior and relationships). Resident 1's 7/18/24 Quarterly MDS indicated the resident was cognitively intact. On 9/24/24 at 9:22 AM Resident 1 stated she/he was only able to access her/his money during the day time. On 9/24/24 at 1:13 PM Staff 22 (CNA) stated if a resident wanted access to their money, she would direct the resident to wait for staff from the CFL (Center for Living, the community mental health program overseeing the facility's enhanced care unit). Staff 22 stated CFL staff were in the facility every day from approximately 9:00 AM to 7:00 PM. On 9/24/24 at 1:24 PM Staff 21 (CNA) stated she did not deal with any money things and the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-27 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview it was determined the facility failed to maintain a homelike environment and adequate hot water temperatures for 1 of 1 facility shower room reviewed for a homelike environment. This placed residents at risk for a cluttered and damaged shower environment as well as cold showers. Findings include: On 9/23/24 at 10:23 AM Resident 32 stated the water in main shower room was too cold. On 9/26/24 at 7:43 AM Resident 100 stated the water would go hot for a bit and then suddenly get cold. On 9/26/24 at 7:01 AM Staff 11 (CNA) stated she started the shower way ahead of time so the water could warm up. Staff 11 stated sometimes the water was too cold. On 9/26/24 at 7:56 AM staff 19 (maintenance director) tested the shower water temp after five or more minutes and it was 87 degrees F. Staff 19 indicated which hot water heater supplied the shower and the temperature gauge read 99 degrees F. On 9/27/24 at 7:26 AM Staff 1 (Administrator) tested the shower water temperature and it reached 94 degrees Fahrenheit. On 9/27/24 at 7:26 AM the main shower room was…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-27 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 PASARR Level II (Preadmission Screening for individuals with a mental disorder and/or individuals with intellectual disability) was completed for 2 of 2 sampled residents (#s 9 and 26) reviewed for PASARR. This placed residents at risk for not receiving specialized services. Findings include: The facility's 9/2024 PASARR Policy and Procedure directed the following: -If a Level II evaluation was indicated, the social worker would ensure a LMPH (licensed mental health professional) was scheduled to evaluate within a timely period. -If there was a significant change of condition that could affect a resident's diagnosed need for a PASARR Level II, staff should refer for a new PASARR Level II. -Follow up as needed per federal PASARR rules. 1. Resident 9 was admitted to the facility in 7/2024 with diagnoses including Schizoaffective disorder (a mental health condition marked by a mix of schizophrenia symptoms, such as hallucinations…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-27 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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 to reflect the needs of residents for 2 of 4 sampled residents (#s 14 and 35) reviewed for weights and assistive devices. This placed residents at risk for unmet needs. Findings include: 1. Resident 14 was admitted to the facility in 6/2020 with diagnoses including dementia and parkinsonism (difficulty with movement). Resident 14's 7/2/24 Annual MDS revealed the resident was moderately cognitively impaired. A Care Plan dated 7/11/24 revealed Resident 14 used a mobility bar on the left side of the bed for inhanced bed mobility. Observations from 9/23/24 through 9/27/24 revealed Resident 14 did not have a mobility bar in place while the resident was in bed. On 9/26/24 at 9:51 AM Staff 11 (CNA) stated Resident 14 should have a bed mobility bar on her/his bed to help her/him with positioning while in bed. On 9/26/24 at 10:59 AM Staff 9 (LPN Resident Care Manager) stated Resident 14 had a mobility bed assist rail on her/his bed to assist with…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-27 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    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 an on-going program to support individual activity interests and preferences for 1 of 2 sampled residents (#25) reviewed for activities. This placed residents at risk for lack of social interaction and isolation. Findings include: The facility's 3/2019 Activities Policy and Procedure indicated the following: -Each resident's physical, mental, spiritual, psychosocial and leisure choices as well as preferences for participation in activities will be assessed. This assessment will occur on admission, annually and with condition changes. -A monthly calendar shall be posted in designated areas of the facility. The scheduled activities will be planned at an appropriate frequency to provide diverse activity/recreational programs that address various cognitive and functional levels and meet the needs of the residents. Resident 25 was admitted to the facility in 1/2021 with a diagnoses including dementia and depression. Resident 25's 1/17/24 Annual MDS indicated the resident experienced short…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 interview and record review it was determined the facility failed to provide care in accordance with care planned interventions while transferring residents for 1 of 1 sampled resident (#31) reviewed for accidents. This failure resulted in avoidable skin tears to Resident 31's right arm. Findings include: Resident 31 was admitted to the facility in 9/2023 with diagnoses including stroke and kidney failure. Resident 31's Quarterly MDS dated [DATE] indicated the resident was moderately impaired in cognition. Resident 31's Care Plan dated 10/3/23 identified the resident was at risk for falls due to muscle weakness. Interventions on the care plan included: Two-person transfers with a hoyer lift, staff were to anticipate the resident's needs and to keep the call light and personal items within reach. A 12/6/23 Facility Reported Incident indicated Resident 31 was provided care by Staff 11 (CNA) and Staff 15 (CNA) during a transfer from bed to her/his wheelchair and sustained two skin tears to her/his right…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-27 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review it was determined the facility failed to ensure residents who were trauma survivors received trauma-informed care for 1 of 2 sampled residents (#1) reviewed for mood. This placed residents at risk for re-traumatization and decreased quality of life. Findings include: Resident 1 was admitted to the facility in 10/2017 with diagnoses including borderline personality disorder (a mental disorder characterized by unstable moods, behavior and relationships). The National Institute of Mental Health (NIMH) website section titled Borderline Personality Disorder indicated genetic, environmental and social factors may increase a person's risk of developing borderline personality disorder, and many people with borderline personality disorder report experiencing traumatic life events, such as abuse, abandonment or hardship during childhood. Resident 1's 7/18/24 Quarterly MDS indicated the resident was cognitively intact. On 9/24/24 at 9:17 AM Resident 1 was observed in her/his room in her/his wheelchair. Resident 1 stated she/he had a history 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-27 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview it was determined the facility failed to ensure medications and biologicals were secured and accessible only to authorized personnel for 1 of 1 facility observed for secure medication and treatment carts. This placed residents at risk for misappropriation of medications and adverse medication consequences. Findings include: The facility Medication Storage Policy dated 1/2024 stated: In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access. On 9/23/24 at 1:27 PM the treatment cart near the 300 hall was unlocked and unattended by staff. On 9/23/24 at 1:32 PM Staff 2 (DNS) confirmed the cart was left unlocked and unattended. On 9/26/24 at 1:19 PM the medication cart on the 500 hall was unlocked and unattended by staff. On 9/26/24 at 1:23 PM Staff 10 (LPN) confirmed…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-18 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review it was determined the facility failed to protect the resident's right to be free from physical abuse by another resident for 1 of 3 sampled residents (#101) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 101 was admitted to the facility in 7/2020 with diagnoses including alcohol-induced dementia. Resident 101's 3/18/22 Quarterly MDS indicated the resident was cognitively intact. Resident 100 was admitted to the facility in 7/2021 with diagnoses including Lewy body dementia (a brain disorder that can lead to problems with thinking, movement, behavior and mood). Resident 100's 8/8/21 Behavior Care Plan revealed the following: -The resident experienced agitation and aggression. -Staff were to intervene as necessary to protect the rights and safety of others. Resident 100's 2/4/22 Quarterly MDS indicated the resident was severely cognitively impaired and was able to walk independently. A 4/2/22 FRI and Investigation revealed the following: -Staff 3 (admission Director) heard yelling and cursing…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 it was determined the facility failed to ensure adequate supervision and a safe environment for 1 of 3 sampled residents (#100) reviewed for elopement. This placed residents at risk for injury from accidents. Findings include: Resident 100 was admitted to the facility in 7/2021 with diagnoses including Lewy body dementia (a brain disorder that can lead to problems with thinking, movement, behavior and mood). Resident 100's 7/29/21 At Risk for Falls and ADL Care Plans revealed the following: -The resident was considered at high risk of falling. -The resident ambulated independently in the facility. -The resident used a front wheeled walker when ambulating on uneven surfaces. Resident 100's 3/17/22 Elopement Risk/Wanderer Care Plan revealed the following: -The resident was considered at risk to elope. -The resident wore a Wanderguard (a monitoring device that allows an alarm to be activated when a person attempts to leave a safe area). -The resident required frequent checks during routine rounds due to her/his dementia, independence with mobility…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2020-01-31 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review it was determined the facility failed to ensure food was served at an appetizing temperature for 3 of 4 halls and 3 of 3 sampled residents (#s 10, 40 and 350) reviewed for food. This placed residents at risk for an unappetizing dining experience. Finding include: 1. The 10/2019 Resident Council Meeting Minutes revealed food was served cold. The facility's response was to monitor the food temperatures on the room tray carts and in during dining services. The 11/2019 Resident Council Meeting Minutes revealed residents voiced concerns related to cold eggs and burnt foods. The facility's response was to educate staff about the burnt items and monitor the food temperatures. On 1/29/20 at 8:40 AM a breakfast test tray from the hall cart which served halls 100, 200, 300 and 400 was sampled by the state survey team. The pancakes and eggs were observed to be lukewarm. In an interview on 1/31/20 at 9:19 AM Staff 16 (Dietary Manager) stated she was aware of concerns related to cold foods. Staff 16 stated she sent test trays and monitored the…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-01-31 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop 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 ensure residents' care-planned interventions were followed for 1 of 1 sampled resident (#45) identified with a fall with injury. As a result, Resident 45 sustained a left arm fracture on 12/23/19. The facility identified the noncompliance and immediately initiated a plan of correction which included staff education, staff reminders to read residents' care plans daily and implement care planned interventions and no further accidents occurred. This incident was identified as meeting the criteria for past noncompliance. Findings include: Resident 45 was admitted to the facility in 12/2019 with diagnoses including sepsis (systemic infection). Resident 45's 12/18/19 admission MDS Section C: Cognitive Patterns indicated moderate cognitive impairment with a BIMS score of 12. Resident 45's Care Plan identified the resident as a fall risk. The fall prevention intervention directed staff to ensure Resident 45 used non skid footwear when transferring. On 12/23/19 at approximately 5:45 PM Staff 13 (CNA)…

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

    Resident Assessment and Care Planning Deficiencies · Past Non-Compliance
  • Potential for harm · D2020-01-31 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to monitor, obtain physician's orders and failed to implement a treatment for 1 of 1 sampled resident (#350) reviewed for pressure ulcers. This placed residents at risk for unmet needs. Findings include: Resident 350 was admitted to the facility in 1/2020 with diagnoses including a Stage 2 pressure ulcer of the coccyx, systolic and diastolic Congestive Heart Failure and anemia. On 1/15/20 SNF admission Nursing Database revealed Resident 350 had a stage 2 pressure wound on her/his coccyx. The admission orders did not address pressure ulcer wound treatment. There was no wound documentation or treatments found between 1/15/20 and 1/19/20. On 1/19/20 Staff 18 (RN) was notified there was bleeding on Resident 350's coccyx when toileting. Staff 18 examined coccyx and noted redness and measured wound at 0.25 x 0.5 cm. Staff 18 covered the wound with Zinc (ointment per facility's wound care protocol) and educated the resident on the importance of moving off of her/his back. The 1/26/20 at 1:00 PM Progress Note written…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-01-31 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    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 a resident's food preference was honored for 1 of 3 (#40) sampled residents reviewed for food. This placed residents at risk for food preferences not being honored. Findings include: Resident 40 was admitted to the facility in 1/2019 with diagnoses including burns and tracheostomy (tube into the windpipe) use. The 1/14/19 Food and Nutrition Services admission Interview revealed the resident did not like pork. The 1/30/20 monthly menu revealed lunch was pork and vegetable stir fry. Resident 40's 1/30/20 dietary slip had pork listed as a dislike. The 1/30/20 Health Status Note, completed by Staff 15 (RN), revealed Resident 40 reported choking on lunch, was coughing and gasping but had audible air profusion. The resident's O2 sat was at 94 percent or above, lung sounds throughout. Resident 40 was suctioned and reported improvement. Pork was noted as a dislike and Resident 40 stated it made her/him choke. The lunch was pork bite sized pieces in sauce. On 1/30/20 at 1:48 PM Resident 40 stated she/he…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-01-31 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard 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 document interventions to ensure resident's privacy was respected for 1 of 1 sampled resident (#41) reviewed for privacy. This placed residents at risk for an incomplete clinical record and unmet needs. Findings include: Resident 41 was admitted to the facility in 5/2017 with diagnoses including a stroke. The 12/28/19, 12/29/19, 1/1/20, 1/2/20, 1/3/20, 1/5/20 and 1/6/20 Progress Notes revealed Resident 41 voiced concerns related to sleep disruption due to her/his roommate. A 1/2/20 Progress Note indicated staff attempted to do the roommate's treatment in the evening in attempts not to disrupt Resident 41's sleep as much. No additional documentation was found related to interventions attempted by staff to improve Resident 41's sleep disruptions. In an interview on 1/30/20 at 9:02 AM and 1/31/20 at 11:31 AM Resident 41 stated she/he was woken up at nights and it was frustrating. Resident 41 stated the facility offered some interventions such as ear plugs. Resident 41 could not recall if they offered her/him…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$38,636 in federal fines across 1 penalty.

  • $38,636 — penalty dated 2024-09-27

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

Part of a chain

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

RatingThis homeChain avg
Overall 3 of 52.9+0.1 vs chain
Health inspection 2 of 52.5-0.5 vs chain
Staffing 4 of 52.5+1.5 vs chain
Quality measures 5 of 54.4+0.6 vs chain
The other 273 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Anchor Post AcuteAiken, SC 1 of 5Arbor Post AcuteChico, CA 1 of 5Artesia Palms Care CenterArtesia, CA 1 of 5Arvin Post AcuteArvin, CA 1 of 5Ashland Post AcuteAshland, OR 1 of 5Bakersfield Post AcuteBakersfield, CA 1 of 5Beachwood Post-Acute & RehabSanta Monica, CA 1 of 5Brookshire Post AcuteDenver, CO 1 of 5Brushy Creek Post AcuteGreer, SC 1 of 5Buckeye Care And RehabilitationLancaster, OH 1 of 5Carnegie Park Post AcutePittsburgh, PA 1 of 5Cascade Terrace Post AcutePortland, OR 1 of 5Centennial Post AcuteAnchorage, AK 1 of 5Chandler Creek Post AcuteGreer, SC 1 of 5Chehalem Post AcuteNewberg, OR 1 of 5Country Hills Post AcuteEl Cajon, CA 1 of 5Delhi Post-AcuteCincinnati, OH 1 of 5Dublin Post AcuteDublin, OH 1 of 5Edisto Post AcuteOrangeburg, SC 1 of 5Evan Terrace Post AcuteMcMinnville, OR 1 of 5Forest Acres Post AcuteColumbia, SC 1 of 5Grandview Post AcuteCookeville, TN 1 of 5Great Plains Post AcuteWichita, KS 1 of 5Hemet Hills Post AcuteHemet, CA 1 of 5Highland Hills Post AcutePittsburgh, PA 1 of 5Highline Post AcuteDenver, CO 1 of 5Johns Island Post AcuteJohns Island, SC 1 of 5Karcher Post AcuteNampa, ID 1 of 5Kennedy Care CenterLos Angeles, CA 1 of 5Kern River Transitional CareBakersfield, CA 1 of 5Lakeview Post AcuteFlorissant, MO 1 of 5Marion Valley Post AcuteMarion, OH 1 of 5Mirage Post AcuteLancaster, CA 1 of 5Monroeville Post AcuteMonroeville, PA 1 of 5Napa Post AcuteNapa, CA 1 of 5North Royalton Post AcuteParma, OH 1 of 5Northstar Post AcuteCarson City, NV 1 of 5Overland Park Post AcuteOverland Park, KS 1 of 5Pikes Peak Post AcuteColorado Springs, CO 1 of 5Ridgeway Post AcutePetaluma, CA

Showing 40 of 273; lowest-rated first.

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

Who owns this facility

Owner / managerTypeRoleShareSince
MITCHELL, JOHNIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICERNO PERCENTAGE PROVIDEDsince 09/01/2024
APT, FREDERICKIndividualCORPORATE OFFICERsince 09/01/2024
JERGENSEN, JOSHUAIndividualCORPORATE OFFICERsince 09/01/2024
FARRAR, CHANDAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/28/2025
GOBBO, ROBERTIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/28/2025

CMS files one row per role, so the 8 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.

Follow the money — this home’s finances

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

$9.6M
Net patient revenuemost recent cost report
+8.9%
Operating marginrevenue minus expenses
$696K
Related-party expense8% of expenses
Who pays — share of resident-days
Medicaid 74%Medicare 10%Other / private 15%

About 74% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $696K 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

$502per resident / day
operating cost
$15,255per month
≈ monthly operating cost
$551per day
avg. revenue, all payers

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

What families pay in OR

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 385104. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-13, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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