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Independence Health And Rehabilitation

1525 Monmouth Street, Independence, OR 97351 · For profit - Limited Liability company · 80 certified beds · (503) 838-0001 Medicare & Medicaid certified

Call the home — (503) 838-0001 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 actual-harm citation$69,876 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $69,876 in federal fines (most recent 2025-02-18)
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)
  • nursing-staff turnover (65%) runs well above the national median (45%)

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

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

2/5
CMS overall
2 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 2 of 5

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1601 Monmouth St · (503) 838-0045 · Call to confirm hours
Pharmacy
1397 Monmouth Independence Hwy · (503) 838-1176 · Call to confirm hours
Grocery
1405 Monmouth St · (503) 751-1034 · Call to confirm hours
Park
N Hogan Rd · Typically dawn to dusk
Place of worship
1505 Monmouth St · (503) 838-1001

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 2 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 1 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 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.

Overall rating4★
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 increased10.2%14.9%15.4%better
Long-stay residents who lose too much weight3.9%4.7%5.4%better
Long-stay residents with a catheter left in their bladder0.0%1.4%0.9%better
Long-stay residents with a urinary tract infection0.9%2.0%2.0%better
Long-stay residents with depressive symptoms1.0%4.9%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.7%2.4%3.3%better
Long-stay residents on antianxiety or hypnotic medication14.3%12.4%18.9%better
Long-stay residents given the seasonal flu vaccine94.3%95.2%95.3%typical
Long-stay residents with pressure ulcers5.3%5.8%4.7%worse
Long-stay residents with worsening bladder/bowel control19.7%21.8%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table14.7%13.9%17.1%better
Short-stay residents who newly got an antipsychotic medication3.1%1.4%1.4%worse
Short-stay residents given the seasonal flu vaccine98.0%81.2%79.4%better
Short-stay residents rehospitalized after admission21.0%21.4%22.6%typical
Short-stay residents with an outpatient ER visit31.8%16.1%12.0%worse

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

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

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

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

11.3%U.S. median 10.7%
Went back to hospital
0.18U.S. median 0.31
Therapy hours / resident / day
0.10hours / resident / day
Physical therapy
0.07hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.18 therapist hours per resident per day in 2026Q1 — more than 18% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% 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 SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.3%CMS range 7.4–16.110.7%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot 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 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.031.02Oct 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

0.54
RN hours/ resident / day
1.06
LPN hours/ resident / day
3.69
Aide hours/ resident / day
5.29
Total nurse hours/ resident / day
0.48
RN hoursweekends
65.1%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 80 beds and averages 34.8 residents a day — about 43% occupied, or roughly 45 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.29 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.54 is below the 0.55-hour RN benchmark and nurse-aide staffing of 3.69 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 4.70 hrs/resident/day on weekends vs 5.53 on weekdays — 15% thinner on weekends. RN hours go from 0.57 to 0.48 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 65% is well above the national median of 45%.

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

Inspection trend

14
deficiencies at the latest standard inspection (2026-05-11)
9
at the previous standard inspection (2025-02-18)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

31 citations, most serious first. The 11 most serious are shown; the remaining 20 are one tap away and print in full.

  • Actual harm · Gcited before2025-02-18 · 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 a resident was transferred as care planned for 2 of 2 sampled residents (#s 2 and 31) reviewed for falls. this placed residents at risk for injury. Findings include: 1. Resident 2 admitted to the facility in 1/2007 with diagnoses including dementia (a group of symptoms affecting cognition, memory and social relationships) and hemiplegia following cerebral infarction (paralysis of one side of the body following a stroke caused by a blood clot in the brain). Resident 2 was non-verbal and unable to be interviewed due to dementia. A review of the Physician Encounter note dated 8/25/24 revealed the resident was transported to the emergency department following a fall on 8/25/24. Resident 2 was diagosed at the hospital with a fracture of the right femural neck (a break in the bone that connects the ball of the hip to the thigh bone). A review of the resident's care plan indicated Resident 25 required the assistance of two caregivers for toileting and personal care. In an interview on 2/12/25 at 5:02 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2026-05-11 · tag F0908 — failed to keep essential equipment working — widespread
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review it was determined the facility failed to maintain essential kitchen equipment for 1 of 1 kitchen reviewed for kitchen services. This placed residents at risk for food borne illnesses. Findings include:The 12/5/07 manufacturer specifications for the Ecolab Model ES-2000 indicated the dishwasher required a minimum wash and rinse temperature of 120 degrees Fahrenheit and a recommended temperature of 140 degrees Fahrenheit.On 5/7/26 at 12:17 PM, an observation of the facility kitchen revealed the dishwasher temperature gauge was hazed and unreadable. Staff 16 (Registered Dietician) acknowledged the gauge was unreadable. She stated Dietary Manager was on vacation. She was unsure of the dishwasher's status and requested maintenance assistance.A review of the May 2026 dishwasher log did not include temperature monitoring.On 5/7/26 at 12:24 PM, Staff 15 (Maintenance Supervisor) acknowledged the temperature gauge was unreadable and needed to be replaced. Staff 15 stated the dishwasher temperature was tested with a thermometer on a regular…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-05-11 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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 — the official record, unedited, may be distressing

    Based on observation and interview it was determined the facility failed to store food in a sanitary manner for 1 of 1 kitchen reviewed for food safety. This placed residents at risk for foodborne illnesses. Findings include:On 5/4/26 at 9:34 AM, a brief kitchen tour was completed and revealed the following:-An opened bag of cereal in dry storage was unlabeled and undated.-An opened container of ranch dressing in the refrigerator was undated.-An open bag containing eight boiled eggs in the refrigerator was unlabeled and undated.-An open block of cheese in the refrigerator was loosely wrapped and undated.On 5/4/26 at 9:36 AM, Staff 13 (Cook) stated staff were to date food products when opened and add a use-by date. Staff 13 confirmed the open items were undated and stated she would discard them.On 5/7/26 at 11:38 AM, Staff 16 (Registered Dietician) stated staff were to date any food product immediately when opened and discard any items found without dates.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-05-11 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review it was determined the facility failed to implement measures to prevent the spread of infection related to catheter positioning, hand hygiene, and Enhanced Barrier Precautions for 1 of 1 staff member (Staff 8) reviewed during a random observation and 3 of 11 sampled residents (#s 4, 8, and 29) reviewed for infection control. This placed residents at risk for infections. Findings include: 1. On 5/4/26 at 1:32 PM, Resident 4's catheter was observed to be attached to her/his bed with part of the catheter resting on the floor. On 5/6/26 at 11:59 AM Resident 4 was observed with part of the catheter attached to the bed and part of it rested on the floor. On 5/6/26 at 9:00 AM Staff 21 (CNA) observed Resident 4's catheter and confirmed it rested on the floor. On 5/6/26 at 10:29 AM Staff 9 (CNA) observed Resident 4's catheter and confirmed it rested on the floor. Staff 9 stated a barrier between the catheter and the floor was required. Staff 9 raised Resident 4's bed slightly and placed a basin under the catheter. On 5/8/26 at 1:32 PM Staff 4…

    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 · Ecited before2026-05-11 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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 influenza and pneumococcal vaccines for 3 of 5 sampled residents (#s 4, 6, and 14) reviewed for immunizations. This placed residents at risk for influenza and pneumonia. Findings include: 1 Resident 4 was admitted to the facility in 2024 with diagnoses included multiple sclerosis (an autoimmune disease which affects the central nervous system). A review of Resident 4's immunization record revealed no documentation she/he was offered or received an influenza vaccine in 2025.On 5/8/26 at 3:13 PM Staff 3 (Assistant Director of Nurses/LPN Resident Care Manager) stated she reviewed Resident 4's documentation and confirmed there was no evidence Resident 4 was offered or received an influenza vaccine.2. Resident 6 admitted to the facility in 2025 with diagnoses including osteomyelitis (bone infection). A review of Resident 6's immunization record revealed she/he received a PCV 13 in 2017.A review of the CDC Pneumococcal Vaccine Recommendations revealed Resident 6 required another dose of a pneumococcal…

    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 · E2026-05-11 · tag F0887 — pattern
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    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 offer a COVID-19 vaccine for 3 of 5 sampled residents (#s 4, 6, and 14) reviewed for immunizations. This placed residents at risk for COVID-19. Findings include: 1. Resident 4 was admitted to the facility in 2024 with diagnoses included multiple sclerosis (an autoimmune disease which affects the central nervous system). A review of Resident 4's immunization record revealed no documentation she/he was offered or received a COVID-19 vaccine in 2025.On 5/8/26 at 3:13 PM Staff 3 (Assistant Director of Nurses/LPN Resident Care Manager) stated she reviewed Resident 4's documentation and confirmed there was no evidence Resident 4 was offered or received a COVID-19 vaccine.2. Resident 6 admitted to the facility in 2025 with diagnoses including osteomyelitis (bone infection). A review of Resident 6's immunization record revealed she/he did not have documentation of a COVID-19 vaccine in 2025.A review of Resident 6's medical record revealed a 11/4/25 Multi-Vaccine Consent Form signed by Resident 6, and the COVID-19…

    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 · Dcited before2026-05-11 · 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 residents were informed of the risks and benefits of psychotropic medications for 2 of 5 sampled residents (#s 4 and 43) reviewed for unnecessary medications. This placed residents at risk for uninformed about their medications. Findings include: 1. Resident 4 admitted to the facility in 2024 with diagnoses including depression. Resident 4's physician orders revealed a 1/6/26 order for citalopram (an antidepressant). A review of Resident 4's medical record revealed no indication she/he was informed in advance of the risks and benefits of citalopram. On 5/11/26 at 1:19 PM Staff 2 (DNS) confirmed Resident 4 was not informed of the risks and benefits of citalopram. 2. Resident 43 was admitted to the facility in 5/2026 with diagnoses including esophageal obstruction (narrowed esophagus). Resident 43's 5/2/26 Physician Orders indicated the resident was prescribed clonazepam (antianxiety medication) for anxiety. Review of Resident 43's medical record revealed no indication the resident was informed in…

    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 before2026-05-11 · 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 — the official record, unedited, may be distressing

    Based on observation, interview and record review it was determined the facility failed to ensure residents had unsoiled clean linens for 1 of 3 linen closets reviewed for environment. This placed residents at risk for a lack of a homelike environment. Findings include:On 5/6/26 at 10:26 AM the left lower corner of the east hall linen closet was observed to have multiple black spots. On 5/6/26 at 11:10 AM Staff 11 (CNA) stated there was a mold odor in the east linen closet at times. Staff 11 opened the east linen closed and confirmed there appeared to be mold in the lower left corner of the closet with multiple blankets touching the black spots on the wall. Staff 11 removed the blankets and sent them to laundry. On 5/6/26 at 12:03 PM Staff 15 (Maintenance Supervisor) stated he was unaware of any concerns with mold in the east linen closet. Staff 15 looked in the linen closed and confirmed there was mold in the lower left corner.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-11 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to complete a Significant Change MDS within the required timeframe for 1 of 1 sampled resident (#6) reviewed for hospice. This placed residents at risk for unassessed hospice needs. Findings include: Resident 6 admitted to the facility in 11/2025 with diagnoses including osteomyelitis (an infection in the bone). A 4/21/26 Progress Note revealed Resident 6 admitted to hospice services on 4/21/26. A Significant Change MDS assessment dated [DATE] was completed on 5/7/26, 17 days after Resident 6 admitted to hospice. On 5/8/26 at 10:55 AM Staff 18 (MDS Coordinator) reviewed Resident 6's Significant Change MDS and confirmed it was not completed within 14 days after Resident 6 was admitted to hospice.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-11 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to provide personal care for 1 of 4 sampled residents (#34) reviewed for ADLs. This placed residents at risk for not receiving grooming. Findings include:Resident 34 was admitted to the facility on [DATE] with diagnoses including schizophrenia and major depressive disorder. The 4/22/26 admission MDS indicated Resident 34 had a BIMS score of 14, which indicated the resident was cognitively intact, and required staff assistance with personal care, which included shaving.On 5/4/26 at 11:27 AM Resident 34 was observed in her/his room with facial hair that was long and thick. Resident 34 stated she/he preferred short facial hair, but staff did not offer to trim or shave her/his facial hair since admission into the facility.On 5/6/26 at 1:56 PM Staff 10 (CNA) stated she worked with Resident 34 on 5/5/26 but did not offer to shave or trim the resident's facial hair. On 5/6/26 at 2:16 PM Staff 6 (CNA) stated she provided care to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-11 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to provide PRN bowel medication for 1 of 5 sampled residents (#34) reviewed for unnecessary medications. This placed residents at risk for unmet bowel care needs. Findings include:The facility's Bowel Protocol policy dated 5/2025 stated if a resident does not have a bowel movement for three days, the nurse administers the physician ordered bowel program.Resident 34 admitted to the facility on [DATE] with diagnoses including chronic idiopathic constipation. A review of Resident 34's Physician Orders dated 4/17/26 included sennoside 8.6 mg and polyethylene glycol 3350 powder, for constipation on a PRN basis. The Physician Orders also indicated the resident was to receive Milk of Magnesia for constipation on a PRN basis after three days of no bowel movement.A review of Resident 34's bowel record indicated the resident had no bowel movement from 4/21/26 to 4/24/26 (four days). A review of Resident 34's 4/2026 MAR revealed no indication the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 20 citations
  • Potential for harm · D2026-05-11 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record reviewed it was determined the facility failed to implement wound care interventions as ordered for 1 of 1 sampled resident (#40) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include: Resident 40 was admitted to the facility in 3/2026 with diagnoses including leg amputation and pressure ulcers.A 3/27/26 physician order indicated staff were to perform wound care to the pressure ulcers on Resident 40's back every day shift.Progress Notes on 4/6/26 and 4/10/26 indicated wound care was not completed, and staff passed the treatment on to the next shift.On 4/22/26, a complaint was received which indicated Resident 40 was admitted to the facility on [DATE] with multiple unstageable pressure ulcers to her/his back. Witness 3 (Complainant) indicated staff did not always provide wound care, the wounds worsened, and the resident was sent to the hospital.On 5/7/26 at 11:28 AM, Staff 19 (CMA) stated Resident 40 had a bariatric bed and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-11 · 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 observation, interview and record review it was determined the facility failed to ensure physician orders were followed to prevent accidental choking for 1 of 5 sampled resident (#43) reviewed for unnecessary medications. This placed residents at risk for adverse outcomes related to aspiration. Findings include:Resident 43 was admitted to the facility in 5/2026 with diagnoses including esophageal obstruction (narrowed esophagus).Resident 43's 5/1/26 Care Plan indicated she/he required enteral nutrition (tube feeding) related to esophageal obstruction and was to remain NPO (nothing by mouth).Resident 43's 5/1/26 Physician's Orders stated Resident 43 was NPO.On 5/7/26 at 1:34 PM, Witness 2 (Family Member) stated Resident 43 was served juice at breakfast and was now coughing.On 5/7/26 1:54 PM, Resident 8 was observed sitting upright in bed, coughing, and attempting to spit up phlegm.On 5/7/26 at 1:55 PM, Staff 8 (LPN) stated Resident 43 was served juice at breakfast by a CNA. Staff 8 stated Resident 43 consumed approximately half of a sip of juice before it was removed,…

    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 · D2026-05-11 · 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 a catheter bag was properly placed for 1 of 1 sampled residents (#8) reviewed for urinary catheters. This placed residents at risk of urinary tract infections. Findings include: Resident 8 was admitted in 2/2025 with diagnoses including pneumonia (lung infection).The 2/6/26 Annual MDS indicated Resident 8 was cognitively intact and an indwelling urinary catheter was in place.Resident 8's Care Plan, revised on 12/17/25, identified the presence of an indwelling urinary catheter. Care Plan Interventions included to change from a leg bag to drain bag for day and night use and encourage proper positioning of the catheter and drainage bag.Multiple observations on 5/4/26 through 5/6/26 between 9:00 AM to 4:00 PM revealed Resident 8 sat in a wheelchair with the catheter drainage bag placed on her/his wheelchair seat, above the bladder, between the resident's leg and the arm rest.On 5/6/26 at 9:03 AM Staff 10 (CNA) stated Resident 8 frequently placed the catheter bag above her/his bladder and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-02-18 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview it was determined the facility failed to maintain a comfortable interior for 2 of 2 residents (#29 and 35) and 1 of 1 hall reviewed for a homelike environment. This placed residents at risk for an unhomelike environment. Findings include: 1.Resident 297 was admitted to the facility in 12/2024 with a diagnosis of varicose veins of left lower extremity. A 12/5/24 MDS revealed Resident 297 was cognitively intact. On 2/12/25 at 9:20 AM, Resident 35's room was observed with an unpainted area behind the headboard with drywall exposed. On 2/12/25, Resident 29 stated when she/he moved into the room the wall had been in disrepair for a while. In an interview on 2/12/25 at 2:56 PM, Staff 17 (CNA) stated she was aware of the wall damage in the hallway to include torn drywall with missing paint. Residents' rooms also had drywall exposed and paint missing behind the headboards. Staff 17 acknowledged it should be repaired. In an interview on 2/18/25 at 10:33 AM, Staff 12 (Maintenance Director) Stated the wall had been down for two months from ongoing water…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-18 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    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 implement PASARR (Preadmission screening and resident review/screens for serious mental illness and or intellectual disability) and findings timely for 1 of 1 sampled resident (#19) reviewed for PASARR. This placed residents at risk for lack of mental health resources. Findings include: Resident 19 was admitted to the facility in 9/2020 with mental health diagnoses and a serious visual impairment. A 2/15/24 Resident Review PASRR II (Screening for mental illness) form revealed Resident 19 was at risk for self-endangering, heard voices, and was agoraphobic (fear of open spaces or crowded places/fear of leaving one's own home). A mental health evaluation was indicated and was to be completed within 14 days. A 2/22/24 PASRR Level II Evaluation revealed Resident 19 had mental health diagnoses, dementia, and depression. Recommendations made after the evaluation included: -consider increasing her/his Abilify (antipsychotic medication) -make a referral to a psychiatric prescriber for medication…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-18 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined the facility failed to provide care and services for skin wounds for 1 of 1 sampled resident (#8) reviewed for non-pressure skin wounds. This placed residents at risk for worsening wounds. Findings include: The 1/2025 facility's Skin Integrity policy indicated the following for residents: The nurse establishes a plan of care based on risk factors (factors that increase the chance of a problem). The resident's skin is inspected daily with completion of ADLs, with changes reported to the nurse. Ongoing evaluation continues weekly for a full body skin audit (an examination). -For skin impairment identified with admission (abrasion, bruise, burn, excoriation, pressure sore, rash, skin tear, surgical wound etc.) the nurse would complete the following: Document the skin impairment, including measurements of size, color, presence of odor, exudates (fluid), and presence of pain associated with the skin impairment in the weekly wound evaluation for surgical, pressure, burns, and venous stasis ulcer (a sore on the leg…

    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 · D2025-02-18 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide 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 a resident received a restorative program for 1 of 1 sampled resident (#31) reviewed for mobility. This placed residents at risk for decreased ROM. Findings include: Resident 31 was admitted to the facility in 7/2023 with a diagnosis of a stroke. A 7/11/24 OT RA program referral form revealed Resident 31 was discharged from skilled therapy and staff were to assist the resident in maintaining strength, endurance, and improve ROM. Staff were to provide a resting hand splint to the left hand and Resident 31 was to be assisted with exercises using elastic bands and weights. A 12/3/24 quarterly MDS revealed Resident 31 was cognitively intact. Resident 31's record revealed no evidence staff provided RA per OT's 7/11/24 referral. On 2/9/25 at 10:50 AM Resident 31 stated she/he had decreased ROM to her/his left arm and staff did not provide ROM. Resident 31 was observed to have weakness when she/he attempted to lift her/his left arm. A splint was not observed. On 2/12/25 at 7:53 AM Staff 3 (LPN 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-18 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to provide appropriate and timely pain management for 1 of 6 sampled residents (#8) reviewed for medications. This placed residents at risk for uncontrolled pain. Resident 8 was admitted to the facility in 5/2024 with diagnoses including fibromyalgia (a disorder that affects muscle and soft tissue causing chronic muscle pain and tenderness), polyneuropathy (nerves are damaged which can cause burning pain) arthritis and an open wound on the right lower leg. A 5/2024 Care plan revealed Resident 8 was on pain medication therapy due to disease process of lupus and fibromyalgia, contusion of right lower leg and arthritis. To administer medications as ordered by physician, review every shift for pain medication efficacy and assess whether pain intensity was acceptable to resident. Anticipate her/his need for pain relief and respond appropriately to any complaint of pain. A 5/2024 care plan revealed Resident 8 was on pain medication therapy due to the disease process of lupus and fibromyalgia, contusion of the right lower leg, and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-18 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure 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 ensure a resident's physician acted upon pharmacy recommendations timely for 1 of 5 sampled residents (#31) reviewed for medications. This placed residents at risk for an adverse medication regimen. Findings include: Resident 31 was admitted to the facility in 2023 with a diagnosis of heart disease. a. A 11/1/24 Note to Attending Physician/Prescriber indicated the resident current orders were Eliquis (prevents blood clots), clopidrogrel (prevents blood clots), and cilostazol (prevents blood clots). A pharmacy recommendation was made to evaluate the concurrent use of the medications and consider discontinuing the clopidogrel and cilostazol. There was no signature to indicate the physician responded. A 12/3/24 Note to Attending Physician/Prescriber indicated the resident current orders were Eliquis, clopidrogrel, and cilostazol. A pharmacy recommendation was made to evaluate the concurrent use of the medications and consider discontinuing the clopidogrel and cilostazol. There was no signature to indicate 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-18 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure 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 appropriate monitoring and dosing of medications for 1 of 1 of sampled resident (#38) reviewed for diarrhea. This placed the resident at risk for anxiety related to the potential for bowel incontinence and discomfort. Findings include: Resident 38 admitted to the facility 12/2024 with a diagnosis of cerebral hemorrhage. In an interview on 2/11/25 at 9:35 AM Resident 38 stated she/he was having loose stools and was often concerned she/he would not make it to the commode to have a bowel movement. Resident 38 stated she/he spoke to CNAs and an LN about her/his concerns but could not remember which staff. In an interview on 2/12/25 at 10:25 AM Staff 23 (CNA) stated Resident 38 consistently had soft or loose bowel movements and talked to Staff 23 about her/his discomfort and concerns regarding loose stools. Staff 23 stated she talked to the charge nurse about Resident 38's soft or loose stools on multiple occasions. A review of the resident's bowel care task record for 1/2025 and 2/2025 revealed in 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-18 · tag F0919 — failed to provide a working call system — isolated
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    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 bathroom call light cord was present for 2 of 13 sampled residents (#s 9 and 20) reviewed for environment. This placed residents at risk for the inability to call for assistance. Findings include: 1. Resident 20 was admitted to the facility in 8/2020 with a diagnosis of heart failure. A 12/17/24 quarterly MDS revealed Resident 20 was cognitively impaired. A care plan initiated 5/30/24 revealed Resident 20 propelled with a wheelchair, required one staff for transfers, and was not to be left in the bathroom alone. On 2/9/25 at 2:43 PM Resident 20's bathroom was observed without an emergency call light cord to access if she/he fell and was lying on the floor. A 2/17/24 Progress Note revealed Resident 20 was monitored from 2/12/25 to 2/17/25 due to self transfers to the bathroom. On 2/11/25 at 3:37 PM Staff 12 (Maintenance Director) verified there was no emergency call light cord in Resident 20's bathroom. On 2/11/25 at 3:52 PM Staff 13 (Maintenance Assistant) reviewed the maintenance log…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-11-17 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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 and interview it was determined the facility failed to ensure food was stored appropriately and was discarded in a timely manner for 1 of 1 resident refrigerator reviewed for food storage and handling. This placed residents at risk for food-borne illness and decreased food quality. Findings including: On 11/16/23 at 10:33 AM the resident refrigerator located in the therapy kitchen the following was observed: -Opened bottle of fry sauce, expired 7/19/23. -Open and undated bottle of queso con salsa. -Unopened package of hummus used by 11/13/23. -One bowl of cottage cheese and peaches used by 11/13/23. -Three sandwiches used by 11/14/23. -One cup of broth used by 11/14/23. -One mildly thick drink used by 11/14/23. -Two brown-colored juice used by 11/14/23. -Two lettuce salad and dressing used by 11/14/23. -Three bowls of cottage cheese and peaches used by 11/14/23. -Two sandwiches used by 11/15/23. -One cup of broth used by 11/15/23. -One brown-colored juice used by 11/15/23. -Lettuce salad and dressing used by 11/15/23. -One bowl of cottage cheese and peaches used…

    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 · Dcited before2023-11-17 · 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 provide the risk and benefits for the use of psychotropic medication prior to administration for 2 of 5 sampled residents (#s 17 and 27) reviewed for medications. This placed residents at risk for lack of informed consent. Findings include: 1. Resident 17 was admitted to the facility in 2019 with diagnoses including schizoaffective disorder (mental disorder of abnormal thought processes and an unstable mood). Resident 17's 10/20/23 Physician Order indicated the resident was prescribed hydroxyzine (medication used to treat anxiety) PRN for restlessness and agitation. Resident 17's 10/2023 and 11/2023 MARs revealed the resident received 17 doses of hydroxyzine in 10/2023 and eight doses in 11/2023. Review of Resident 17's health record revealed no documentation to indicate the resident's guardian was informed in advance of the risks and benefits of hydroxyzine. The 10/31/23 Psychotropic Drug and Behavior Monthly document indicated Resident 17 did not have a signed consent for hydroxyzine. On 11/16/23 at 8:17…

    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 · D2023-11-17 · 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 — the official record, unedited, may be distressing

    Based on observation, interview and record review it was determined the facility failed to implement a person-centered care plan for 1 of 3 sampled residents (#3) reviewed for accidents. This placed residents at risk for increased injury from falls. Findings include: Resident 3 admitted to the facility in 2/2023 with diagnoses including paralysis and muscle weakness. Resident 3's care plan, initiated on 4/19/23, identified the resident was at risk for falls. Staff were to place fall mats on both sides of Resident 3's bed. On 11/13/23 at 11:31 AM Resident 3 was observed in bed with no fall mats in place. On 11/16/23 at 10:44 AM Resident 3 observed in bed with no fall mats in place. On 11/16/23 at 11:21 AM Staff 9 (CNA) confirmed Resident 3's fall mats were not in place. On 11/16/23 at 12:46 PM Staff 2 (DNS) confirmed fall mats were to be on both sides of Resident 3's bed when she/he was in bed.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-17 · 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 interview and record review it was determined the facility failed to monitor weight loss and reassess the effectiveness of nutrition interventions for 1 of 1 sampled resident (#17) reviewed for nutrition. This placed residents at risk for severe weight loss and malnutrition. Findings include: Resident 17 was admitted to the facility in 2019 with diagnoses including schizoaffective disorder (mental disorder of abnormal thought processes and an unstable mood). Resident 17's 10/27/23 Significant Change MDS indicated the resident was severely cognitively impaired. Resident 17's 7/25/23 Annual Nutrition Evaluation indicated the resident's weight was stable and the resident consumed 76-100% of her/his meals. The 9/5/23 Nutrition Hydration Skin Committee Review indicated Resident 17 consumed 75-100% of her/his meals. According to weight records, Resident 17's 9/1/23 weight was 199.6 pounds. According to weight records, Resident 17's 10/4/23 weight was 183.2 pounds (a weight loss of 16.4 pounds from 9/1/23 to 10/4/23 or 8.22% in 33 days). On 10/13/23 a physician's order for Cal…

    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 before2023-11-17 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure 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 residents were free from unnecessary bowel medications for 1 of 5 sampled residents (#17) reviewed for unnecessary medications. This placed residents at risk for loose stools and diarrhea. Findings include: Resident 17 was admitted to the facility in 2019 with diagnoses including schizoaffective disorder (mental disorder of abnormal thought processes and an unstable mood). The facility's 2020 Bowel Protocol indicated each resident was placed on a bowel monitoring program which the nurse reviewed daily. Resident 17's 11/20/23 Active Order Summary indicated the resident had an order for the following bowel care medications: - polyethylene glycol (a laxative) once daily. - sennosides (a laxative) twice daily. Bowel elimination records from 10/17/23 through 11/15/23 revealed Resident 17 had loose stools documented on the following dates: - 10/17/23 x one - 10/20/23 x one - 10/23/23 x one - 10/30/23 x one - 10/31/23 x one - 11/01/23 x three - 11/02/23 x one - 11/05/23 x one - 11/07/23 x one Resident 17'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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-17 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to administer pneumococcal vaccines for 2 of 5 sampled residents (#s 8 and 17) reviewed for immunizations. This placed residents at risk of contracting communicable illnesses. Findings include: 1. Resident 8 was admitted to the facility in 10/2016 with diagnoses including diabetes. A review of Resident 8's clinical record revealed the resident representative was informed of and consented to receive the pneumococcal vaccine on 4/29/23. There was no evidence to indicate Resident 8 received the pneumococcal vaccine. On 11/17/23 at 10:30 AM Staff 3 (LPN Resident Care Manager) acknowledged the pneumococcal vaccine was not administered to Resident 8. 2. Resident 17 was admitted to the facility in 10/2019 with diagnoses including schizoaffective disorder (mental disorder of abnormal thought processes and an unstable mood). A review of Resident 17's clinical record revealed the resident representative was informed of and consented to receive the pneumococcal vaccine on 4/20/23. There was no evidence to indicate…

    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 · D2023-08-03 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to ensure services provided met professional standards of quality for 1 of 1 sampled resident reviewed (#1) for change of condition. This placed residents at risk for a lack of nursing assessment, acute respiratory failure and hospitalization. Findings include: Resident 1 admitted to the facility in 2021 with diagnoses including chronic respiratory failure and chronic obstructive pulmonary disease (COPD). The Vitals flowsheet revealed Resident 1 had a CNA documented O2 Sat of 85% at 1:14 AM. The 3/21/23 Facility Investigation revealed on 3/21/23 at 12:01 AM Resident 1 was found to have an O2 Sat of 85% on 2 L/m (liters per minute) of oxygen. The CNAs notified the charge nurse (Staff 3, Former LPN) who responded, okay but did not assess the resident. At 4:00 AM the CNAs rechecked Resident 1's O2 Sat, which was 79%. The CNAs again notified Staff 3 who did not assess the resident. A later check revealed an O2 Sat level in the low 70s. The CNAs reported the situation to the day shift nurse upon her arrival to the…

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

    Resident Assessment and Care Planning Deficiencies · Past Non-Compliance
  • Potential for harm · D2023-08-03 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to respond to a change of condition related to a resident's respiratory status for 1 of 1 sampled resident (#1) reviewed for change of condition. This placed residents at risk for respiratory failure and hospitalization. Findings include: Resident 1 admitted to the facility in 2021 with diagnoses including chronic respiratory failure and chronic obstructive pulmonary disease (COPD). The 3/7/23 Hospital Records revealed Resident 1 was in the hospital from [DATE] through 3/7/23 for respiratory failure. The 3/20/23 Progress Notes revealed Resident 1 repeatedly removed her/his oxygen (cannula) on evening shift, her/his oxygen saturation level (O2 Sat) dropped below 90% (normal O2 Sat for a person with COPD is between 88-92%), staff put the oxygen back on Resident 1 and the O2 Sat returned to normal limits. [It is common for a person with a low O2 Sat to be confused and repeatedly remove the oxygen cannula.] The Vitals flowsheet revealed…

    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 · Past Non-Compliance
  • No harm found · C2026-05-11 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and record review it was determined the facility failed to post complete staffing information for 1 of 1 facility reviewed for required staff postings. This placed residents and the public at risk for incomplete and inaccurate staffing information. Findings include:Observations of the Direct Care Staff Daily Reports posted at the facility entrance revealed the evening shift section was left blank on the following dates and times:-5/4/2026 at 2:52 PM-5/5/26 at 3:58 PM-5/6/26 at 3:45 PMOn 5/6/26 at 3:48 PM Staff 8 (LPN) stated the charge nurse was responsible to complete and post the Direct Care Staff Daily Reports at the start of each shift. Staff 8 stated the evening shift started at 2:00 PM and confirmed she did not complete the 5/6/26 evening shift section of the Direct Care Staff Daily Report. On 5/11/26 at 12:46 PM Staff 2 (DNS) stated she was aware of prior incidents when the evening shift section of the Direct Care Staff Daily Reports was not completed and posted timely. Staff 2 stated she expected the charge nurse to complete and post the evening shift…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

“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

$69,876 in federal fines across 3 penalties.

  • $45,819 — penalty dated 2025-02-18
  • $8,018 — penalty dated 2024-01-17
  • $16,039 — penalty dated 2024-01-17

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 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 →

RatingThis homeChain avg
Overall 2 of 52.5-0.5 vs chain
Health inspection 2 of 52.4-0.4 vs chain
Staffing 4 of 53.3+0.7 vs chain
Quality measures 2 of 53.0-1.0 vs chain
The other 43 homes this chain runs (chain average 2.5★, per CMS)
1 of 5Alaska Gardens Health and RehabilitationTacoma, WA 1 of 5El Jen Skilled CareLas Vegas, NV 1 of 5Firesteel Healthcare CenterMitchell, SD 1 of 5Gardnerville Health & Rehabilitation CenterGardnerville, NV 1 of 5Laurel Health & Rehabilitation CenterLaurel, MT 1 of 5Livingston Health & Rehabilitation CenterLivingston, MT 1 of 5Palisade Healthcare CenterGarretson, SD 1 of 5Portland Health And RehabilitationPortland, OR 1 of 5Riverview Healthcare CenterFlandreau, SD 1 of 5Shepherd of the Valley Rehabilitation and WellnessCasper, WY 1 of 5Worland Health and RehabilitationWorland, WY 2 of 5Aspen Meadows Health And Rehabilitation CenterBillings, MT 2 of 5Canterbury HouseAuburn, WA 2 of 5Enumclaw Health and RehabilitationEnumclaw, WA 2 of 5Granite Rehabilitation and WellnessCheyenne, WY 2 of 5Laramie Health and RehabilitationLaramie, WY 2 of 5Mountain View Health And RehabilitationCarson City, NV 2 of 5North Cascades Health and RehabilitationBellingham, WA 2 of 5Seattle Medical Post Acute CareSeattle, WA 2 of 5Shelton Health and RehabilitationShelton, WA 2 of 5Village Health CareGresham, OR 2 of 5Wind River Rehabilitation and WellnessRiverton, WY 3 of 5Fountain Springs HealthcareRapid City, SD 3 of 5La Grande Post Acute RehabLa Grande, OR 3 of 5Pahrump Health And RehabilitationPahrump, NV 3 of 5Prairie View Healthcare CenterWoonsocket, SD 3 of 5Rawlins Rehabilitation and WellnessRawlins, WY 3 of 5Royal Park Health and RehabilitationSpokane, WA 3 of 5Sage View Care CenterRock Springs, WY 3 of 5Thermopolis Rehabilitation and WellnessThermopolis, WY 3 of 5Wheatcrest Hills Healthcare CenterBritton, SD 3 of 5Windsor Health And RehabilitationSalem, OR 4 of 5Americana Health and RehabilitationLongview, WA 4 of 5Buena Vista HealthcareColville, WA 4 of 5Frontier Rehabilitation and Extended CareLongview, WA 4 of 5Hillsboro Health And RehabilitationHillsboro, OR 4 of 5Hot Springs Health & Rehabilitation CenterHot Springs, MT 4 of 5Missoula Health & Rehabilitation CenterMissoula, MT 4 of 5Polson Health & Rehabilitation CenterPolson, MT 4 of 5The Dalles Health And RehabilitationThe Dalles, OR

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 / managerTypeRoleSince
PACIFIC NORTHWEST SNF OPERATIONS HOLDINGS (OR) LLCOrganizationDIRECT OWNERSHIP INTERESTsince 08/31/2023
CH PACIFIC NORTHWEST HOLDINGS LLCOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 08/31/2023
COUVE FINANCIAL SERVICES LLCOrganizationINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/20/2025
INDEPENDENCE SNF OPERATIONS LLCOrganizationINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/12/2025
PACIFIC NORTHWEST SNF OPERATIONS HOLDINGS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 08/31/2023
WITZCORP GLOBAL LLCOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 08/31/2023
HERZKA, YISROELIndividualINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 08/31/2023
YENOWITZ, YITZCHOKIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/31/2023
CEPEDA, MYLENEIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 08/31/2023
ODENTHAL, JASONIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/31/2023
COUVE HEALTHCARE CONSULTING LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/27/2025
OREGON SNF CONSULTING LLC (DE)OrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/28/2025
PACIFIC NORTHWEST OPCO MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/28/2025
DURST, JULIEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/31/2023
HEIMAN, JACOBIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/31/2023
MORRIS, CHRISTOPHERIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/31/2023
SPIELMAN, SHIMONIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/31/2023

CMS files one row per role, so the 37 rows in the source record cover these 17 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.

$4.2M
Net patient revenuemost recent cost report
+12.2%
Operating marginrevenue minus expenses
$100K
Related-party expense3% of expenses
Who pays — share of resident-days
Medicaid 78%Medicare 5%Other / private 17%

About 78% 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 $100K 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

$460per resident / day
operating cost
$13,997per month
≈ monthly operating cost
$524per 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 385188. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-11, 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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