No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Village At Hillside

400 NW Hillside Park Way, McMinnville, OR 97128 · For profit - Limited Liability company · 22 certified beds · (503) 472-9534 Medicare & Medicaid certified

Call the home — (503) 472-9534 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 actual-harm citation
Insights

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

In its favor
  • a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • nursing-staff turnover (69%) 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.

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

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1755 SW Baker St · (971) 900-4522 · Call to confirm hours
Pharmacy
1635 SW Baker St · (503) 472-8423 · Call to confirm hours
Grocery
1595 SW Baker St · (503) 472-3158 · Call to confirm hours
Park
450 SW Westvale St · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 3 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 5 stars. From monthly CMS archive snapshots.

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

Overall rating5★
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 increased13.6%14.9%15.4%better
Long-stay residents who lose too much weight0.0%4.7%5.4%check this — see note marked star below the table
Long-stay residents with a catheter left in their bladder0.0%1.4%0.9%better
Long-stay residents with a urinary tract infection0.0%2.0%2.0%better
Long-stay residents with depressive symptoms4.8%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 injury0.0%2.4%3.3%check this — see note marked star below the table
Long-stay residents on antianxiety or hypnotic medication21.7%12.4%18.9%worse
Long-stay residents with pressure ulcers0.0%5.8%4.7%check this — see note marked star below the table
Long-stay residents with worsening bladder/bowel control38.5%21.8%21.2%worse
Short-stay residents who newly got an antipsychotic medication0.4%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine71.6%81.2%79.4%typical
Short-stay residents rehospitalized after admission34.0%21.4%22.6%worse
Short-stay residents with an outpatient ER visit18.1%16.1%12.0%worse

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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

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

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

63.6% 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 81 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

63.6%U.S. median 51.5%
Got home and stayed home
11.1%U.S. median 10.7%
Went back to hospital
45.7%U.S. median 56.6%
Met the expected recovery
0.71U.S. median 0.31
Therapy hours / resident / day
0.40hours / resident / day
Physical therapy
0.30hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 45.7% 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 35 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 0.71 therapist hours per resident per day in 2026Q1 — more than 92% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 SNF63.6%CMS range 53.1–70.651.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.1%CMS range 7.9–16.410.7%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 discharge45.7%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 discharge37.1%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 discharge31.4%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 identified88.4%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 setting96.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final 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 stay2.3%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 worsened2.3%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 hospitalization7.6%CMS range 3.8–14.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.811.02Oct 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

1.74
RN hours/ resident / day
0.37
LPN hours/ resident / day
4.18
Aide hours/ resident / day
6.29
Total nurse hours/ resident / day
1.14
RN hoursweekends
68.8%
Total nursing turnover
80.0%
RN turnover

How full it usually is: this home is certified for 22 beds and averages 16.8 residents a day — about 76% occupied, or roughly 5 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 6.29 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.74 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 4.18 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 5.76 hrs/resident/day on weekends vs 6.50 on weekdays — 12% thinner on weekends. RN hours go from 1.98 to 1.14 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 69% is well above 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

0
deficiencies at the latest standard inspection (2025-11-25)
6
at the previous standard inspection (2024-07-19)

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.

21 citations, most serious first. The 11 most serious are shown; the remaining 10 are one tap away and print in full.

  • Actual harm · G2023-03-24 · tag F0622 — isolated
    Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
    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 appropriate services and medical equipment were provided at time of discharge for 1 of 3 sampled residents (#11) reviewed for facility discharge. As a result, the unsafe discharge resulted with Resident 11 experiencing unnecessary hardship and pain. Findings include: Resident 11 was admitted to the facility on [DATE] with diagnoses including essential tremors, left hip hemiarthroplasty (partial hip joint replacement). Resident 11's 2/17/23 admission MDS indicated she/he was cognitively intact. A Notice of Medicare Non-Coverage (NOMNC) which notified the resident of skilled services ending was issued on 2/15/23 and indicated skilled services would end on 2/17/23. The physical therapy Discharge summary, dated [DATE], indicated Resident 11 was a moderate fall risk, used a front wheel walker (FWW), and was making progress but limited due to only receiving three treatments. PT discharge recommendations included FWW, daily check-ins…

    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 · Fcited before2024-07-19 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review it was determined the facility failed to use the services of a registered nurse for at least eight consecutive hours a day for 19 of 46 days reviewed for staffing. This placed residents at risk for lack of RN oversight including comprehensive assessments. Findings include: A review of the Direct Care Staff Daily Reports for dates from 6/1/24 through 7/16/24 revealed no RN coverage during the 24-hour period on the following dates: - 6/4/24, 6/5/24, 6/6/24, 6/7/24, 6/10/24, 6/11/24, 6/12/24, 6/16/24, 6/18/24, 6/19/24, 6/22/24, 6/23/24, 6/25/24, 6/26/24, 7/2/24, 7/3/24, 7/6/24, 7/7/24, 7/10/24 In a follow up interview on 7/18/24 at 10:00 AM Staff 1 (Administrator) was informed of the identified dates when the staffing sheets indicated there was a lack of RN coverage. Staff 1 acknowledged there was no RN working as a charge nurse for at least 8 hours on the identified dates.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-07-19 · 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 and interview it was determined the facility failed to provide a sanitary kitchen environment, document food temperatures and ensure staff wore appropriate hair restraints during meal preparation for 1 of 2 kitchens reviewed for sanitation. This placed residents at risk for unsanitary food and cross contamination. Findings include: 1. On 7/15/24 at 9:23 AM and 7/17/24 at 7:21 AM, the inside of the refrigerator in the kitchen was observed to have three small fans circulating air, and each fan had approximately a quarter-inch buildup of dust particles. The ceiling of the refrigerator above the three fans had multiple visible dust particles. Adjacent to the three fans was a black insulated tubing which had visible dust particles on the exterior of the insulated tubing. On 7/17/24 at 10:18 AM Staff 6 (Certified Dietary Manager) and Staff 7 (Registered Dietician) both observed and acknowledged the three fans, the ceiling and the black insulated tubing were dirty and had a visible build-up of dust particles. 2. On 7/15/24 at 9:43 AM and 7/17/24 at 10:16 AM Staff 5…

    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 · D2024-07-19 · 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 inform the resident's representative of the risks and benefits of psychotropic medication for 1 of 5 sampled residents (#8) reviewed for unnecessary medications. This placed residents at risk for not being informed of adverse side effects of medications. Findings include: Resident 8 was admitted to the facility in 7/2023 with diagnoses including dementia and anxiety. Resident 8's 5/5/24 Quarterly MDS indicated Resident 8 had severe cognitive impairment. Resident 8's Profile Sheet, reviewed on 7/18/24, listed a resident representative (Witness 1). Resident 8's record included a Physician Order dated 7/27/23 for citalopram hydrochloride (an antidepressant) 10 MG oral tablets daily. The 7/2023 MAR indicated Resident 8 began receiving the citalopram on 7/28/23. Resident 8's health record revealed a consent for citalopram signed by Witness 1 (Family) on 10/5/23 (more than two months after the resident began receiving citalopram). No evidence was found to indicate Resident 8 and Witness 1 were provided 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-19 · tag F0553 — failed to let residents help plan their care — isolated
    Allow resident to participate in the development and implementation of his or her person-centered plan of care.
    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 include the resident's representative in care planning for 1 of 1 sampled resident (#8) reviewed for care planning. This placed residents at risk for lack of resident-centered care planning. Findings include: Resident 8 was admitted to the facility in 7/2023 with diagnoses including dementia and anxiety. Resident 8's 5/5/24 Quarterly MDS indicated Resident 8 had severe cognitive impairment. Resident 8's Profile Sheet, reviewed on 7/18/24, indicated she/he had a resident representative. A 1/14/24 Collaborative Care document indicated Resident 8 had a care conference on 1/14/24. In an interview on 7/15/24 at 3:01 PM Witness 1 (Family) stated they did not participate in a care conference in the past year. He said he did not get medical information unless he asked for it and Witness 1 said he was not notified of updates/changes to the resident's care plan or outcomes of healthcare provider visits. A review of Resident 8's clinical record revealed no indication that the resident representative was contacted…

    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 · D2024-07-19 · 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 follow up on pharmacist recommendations for 1 of 5 sampled residents (#11) reviewed for unnecessary medications. This placed residents at risk for unnecessary medication administration. Findings include: Resident 11 admitted to the facility in 2023 with diagnoses including migraines and pain. Review of the 7/1/24 physician orders indicated Resident 11 received Depakote (anticonvulsant) BID for migraines and Miralax (laxative) as needed for constipation. Review of Resident 11's pharmacist reviews indicated the following recommendations: - 5/2024 recommended to clarify the order to administer Miralax with food/meals. There was no indication of follow up or a response by the physician. - 7/2024 recommended a gradual dose reduction (GDR) of the Depakote from BID to once a day at bedtime. The physician was noted to indicate yes and accepted the recommendation on 7/3/24. Review of the 7/2024 MAR from 7/4/24 through 7/16/24 indicated Resident 11 was still receiving Depakote BID. Review of the 5/2024, 6/2024 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-19 · 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 did not receive unnecessart blood pressure medication for 1 of 5 sampled residents (#3) reviewed for medications. This placed the resident at risk for low blood pressure. Findings include: Resident 3 was admitted to the facility in 2/2022 with diagnoses including essential hypertension. A review of Resident 3's medication orders revealed an order dated 3/14/24 for verapamil HCI tablet 120 mg (an antihypertensive medication) to be given 1 time a day related to hypertension with instructions to hold for blood pressure less than 100 systolic or 60 diastolic. The order also indicated to hold the medication for pulse less than 60. A review of Resident 3's MARs dated 6/1/24 through 7/15/24 revealed six instances that the verapamil was administered when the resident's blood pressure or pulse were outside of ordered parameters: 6/8/24, 6/9/24, 6/21/24, 6/24/24, 6/26/24 and 7/6/24. During an interview with Staff 8 (RN) on 7/18/24 at 10:28 AM she stated stated she would expect the medication to be…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-03-24 · 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, interview and record review it was determined the facility failed to ensure linens fit residents' beds for 2 of 2 sampled residents (#s 5 and 11) reviewed for linens. This placed residents at risk for uncomfortable sleeping conditions. Findings include: 1. Resident 5 was admitted to the facility in 2019 with diagnoses including diabetes. A 2/23/23 Quarterly MDS indicated the resident had some memory impairment but was able to communicate her/his needs. On 3/20/23 at 10:35 AM Resident 5 stated the fitted bottom sheets did not stay on the mattress. On 3/22/23 at 12:21 PM Resident 5 was observed in bed and the top half of the mattress was exposed. The fitted sheet was only visible to be on at the foot of the mattress. Resident 5 indicated the fitted sheets have been an issue for a long time. On 3/22/23 at 2:22 PM Staff 12 (Housekeeping) stated the facility had a hard time obtaining fitted sheets that fit all the beds. Staff 12 indicated she needed to go to the resident rooms to measure the mattresses and see which sheets fit the beds. On 3/22/23 at 12:24 PM Staff…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-03-24 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    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 staff a licensed nurse on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans and standards of nursing practice for 36 of 113 days reviewed for staffing: This placed residents at risk for lack of care. Findings include: Review of the facility's Pay Based Journal (PBJ) Staffing Data Report for the fiscal year, Quarter 4 (7/2022, 8/2022 and 9/2022) revealed the facility reported the following dates the facility failed to have licensed nursing coverage, no RN or LPN, for 24 hours a day: 7/2/22, 7/16/22, 7/26/22, 7/27/22, 7/30/22, 7/31/22, 8/1/22, 8/2/22, 8/3/22, 8/4/22, 8/5/22, 8/6/22, 8/7/22, 8/8/22, 8/9/22, 8/10/22, 8/11/22, 8/15/22, 8/16/22, 8/17/22, 8/18/22, 8/22/22, 8/27/22, 8/29/22, 8/30/22, 8/31/22, 9/1/22, 9/12/22, 9/13/22, 9/18/22, 9/19/22, 9/20/22, 9/24/22, 9/25/22, and 9/26/22. On 12/28/22 a public complaint alledged on 12/24/22, in the afternoon, a resident did not receive medication due to no (licensed) nurse in the facility. On 3/23/23 at 12:03 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-03-24 · tag F0727 — failed to provide required RN coverage — pattern
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review it was determined the facility failed to staff an RN for 8 consecutive hours per day 7 days per week for 6 out of 113 days reviewed for staffing. This placed residents at risk for lack of timely assessments and care. Findings include: Review of the facility's Pay Based Journal (PBJ) Staffing Data Report for the fiscal year, Quarter 4 (7/2022, 8/2022 and 9/2022) revealed the facility reported the following dates the facility failed to provide staff an RN for eight consecutive hours a day for the following dates: 7/4/22, 7/23/22, 7/24/22, and 8/5/22. The Direct Care Staff Daily Reports from 3/1/23 through 3/20/23 revealed the facility did not have RN staffed on 3/11/23 and 3/18/23. On 3/24/23 at 10:05 AM Staff 1 (Administrator) acknowledged the PBJ Quarter 4 reported information and the 3/11/23 and 3/23/23 lack of RN coverage for 8 consecutive hours a day. No additional information was provided.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-24 · 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 ensure a resident's advance directive was available for staff access in case of an emergency for 1 of 2 sampled residents (#1) reviewed for advance directives. This placed residents at risk for lack of end of life choices being honored. Findings include: Resident 1 was admitted to the facility in 5/2022 with diagnoses including back pain. The 2/26/23 Care Conference form indicated the resident had an advance directive. A 2/2023 Quarterly MDS indicated Resident 1 was cognitively intact. On 3/20/23 at 2:13 PM Resident 1 stated she/he filled out an advance directive. Resident 1's record did not contain a copy of her/his advance directive. On 3/20/23 at 2:20 PM and 3/21/23 at 9:51 AM Staff 2 (DNS) indicated upon admit staff were to ask residents if they had an advance directive. If the resident had one, the staff were to obtain a copy for the resident's record. Staff 2 stated Resident 1 had an advance directive but it was in the resident's previous living community and not in the facility where staff had…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 10 citations
  • Potential for harm · D2023-03-24 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    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 a written notification to 3 of 5 sampled residents (#s 3, 4, and 7) reviewed for Beneficiary Protection Notices. This placed residents at risk for unknown financial liabilities. Finding include: 1. Resident 3 admitted to the facility 10/2014 with diagnoses including asthma and adult failure to thrive. Resident 3 started Medicare Part A services (skilled services including therapy) on 1/23/23. Resident 3's last covered day of Part A services was 2/2/23. A Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) which informed the resident of potential financial liability due to Resident 3 remaining in the facility was not issued. A Notice of Medicare Non-Coverage (NOMNC) which notified the resident of skilled services ending and their rights of appeal was not issued. On 3/22/23 at 10:23 AM Staff 3 (Operations Consultant RN) confirmed a SNF ABN and NOMNC was not issued to Residents 3 and the person who was assigned to issue the forms was not aware the forms were supposed to be…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-24 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review it was determined the facility failed to ensure the ombudsman was notified of a resident's discharge for 1 of 1 sampled resident (#12) reviewed for hospitalization. This placed residents at risk for lack of advocacy assistance. Findings include: Resident 12 was admitted to the facility in 2022 with diagnoses including chronic lung disease. Progress Notes indicated on 1/23/23 Resident 12 reported she/he did not feel well. The resident's physician was notified and the resident was sent to the hospital for evaluation and treatment. The note indicated the family was notified but did not indicate the ombudsman was notified. On 3/24/23 at 8:48 AM Staff 4 (Social Services Director) stated she was new to the facility. Generally they notified the ombudsman and kept a log. The log only went back to 12/2022. Staff 4 stated there was no documentation which indicated the ombudsman was notified of Resident 12's discharge.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-24 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    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 a resident a bed hold policy at the time of hospital transfer for 1 of 1 sampled resident (#12) reviewed for hospitalization. This placed residents at risk for not being informed of her/his rights to return to the facility. Findings include: Resident 12 was admitted to the facility in 2022 with diagnoses including chronic lung disease. A 9/22/22 Bed Hold Agreement signed by Resident 12's spouse indicated they did not wish to hold the bed if Resident 12 was discharged to the hospital. Progress Notes revealed on 1/23/23 Resident 12 reported she/he did not feel well, the physician was notified and the resident was transferred to the hospital for evaluation and treatment. There were no notes to indicate the resident was provided a new bed hold form. On 3/23/23 at 2:51 PM and 3:42 PM Staff 3 (Operations Consultant RN) stated resident's signed a Bed Hold Agreement at the beginning of their facility stay. Staff 3 acknowledged residents were to get a bed hold policy when discharged to the hospital 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-24 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to provide residents with the baseline care plan for 1 of 1 sampled resident (#114) reviewed for new admissions. This placed residents at risk for being uniformed of their plan of care. Findings include: Resident 114 was admitted to the facility on [DATE] with diagnoses including pelvic fracture. Review of the medical record indicated no evidence baseline care plan information was given to Resident 114. On 3/22/23 at 10:47 AM Staff 2 (DNS) and Staff 3 (Operations Consultant/RN) were not aware of baseline care plans which were to be given to the residents. Staff 3 stated Staff 17 (MDS Coordinator) was responsible for the initial resident care plans. On 3/22/23 at 10:49 AM Staff 17 stated the facility did not have a process to provide residents a baseline care plan and information was not given to residents' in the facility which included Resident 114.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-24 · 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 Staff 6 (LPN) adhered to professional nursing standards related to leave the facility with no licensed nurse on duty and to count the medication with a non-licensed staff. This placed residents at risk for adverse health conditions and unmet needs. Findings include: On 12/28/22 a public alledged on 12/24/22, in the afternoon, a resident did not receive medication due to no (licensed) nurse in the facility. On 3/23/23 at 12:03 PM Staff 5 (Human Resources Director) provided a list of names, phone numbers and the hours worked on 12/24/22. The list included the following: -Staff 6 (LPN) worked from 9:49 AM to 4:02 PM. -Staff 8 (CNA) worked 1:54 PM to 10:40 PM. -Staff 10 (LPN) worked 5:56 PM to 6:23 AM (12/24/22). -Staff 21 (CNA) worked 1:20 PM to 10:00 PM. On 3/23/23 at 12:21 PM Staff 6 confirmed she worked on 12/24/22 from 9:49 AM to 4:02 PM. Staff 6 stated when she left at 4:02 PM there was no other licensed nurse in the facility. She stated she was aware the evening nurse could not arrive early for…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-24 · 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

    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 an ongoing program of activities designed to meet the interests and psychosocial well-being of 2 of 3 sampled residents (#s 4 and 5) reviewed for activities. Failure to provide meaningful and regular activities placed residents at risk for unmet psychosocial needs. Findings include: 1. Resident 5 was admitted to the facility in 2019 with diagnoses including depression. An 8/2022 Significant Change MDS and associated CAAs revealed the resident had memory issues but was able to make her/his needs known. A 2/23/23 Quarterly MDS indicated the resident was able to make her/his needs known. A 2/28/23 quarterly activity interest form revealed the resident liked activities including flowers. Group and individual activities from 2/22/23 through 3/22/23 revealed activities were not offered. On 3/20/23 at 10:32 AM Resident 5 stated she/he did not like to leave her/his room to participate in activities but would like to do…

    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 · D2023-03-24 · 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 interview and record review it determined the facility failed to obtain a UA per physician orders and monitor a resident for signs of a UTI for 1 of 1 sampled resident (#2) reviewed for change of condition, failed to follow physician parameters for medication administration for 1 of 5 sampled residents (#2) and failed to document a rationale for a decrease in a resident's antidepressant and monitor the residents after the medication change for 2 of 5 sampled residents (#s 2 and 5) reviewed for medications. This placed residents at risk for delayed treatment and adverse medication reactions. Findings include: 1. Resident 2 was admitted to the facility in 2022 with diagnoses including depression. a. Progress Notes indicated on 12/8/22 Resident 2 had increased confusion, poor intake and a low grade fever. Resident 2's physician was notified and ordered a UA. Resident 2's record did not reveal results of the UA. On 3/22/23 at 10:14 AM Staff 2 (DNS) stated a UA was not obtained per physician orders. b. A 12/8/22 Progress Notes revealed Resident 2 had increased confusion, had…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-24 · 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 — the official record, unedited, may be distressing

    Based on observation and interview it was determined the facility failed to store treatment supplies in locked compartments for 1 of 1 treatment cart observed. This placed residents at risk for accidents. Findings include: On 3/20/23 from 10:03 AM through 10:16 AM an unlocked treatment cart was observed outside of the nurse's station. Staff were observed to walk by the cart but did not lock the cart. There were no residents in the area. On 3/20/23 at 10:22 AM Staff 3 (Operations Consulting RN) stated the treatment cart contained different items used for treatments and confirmed it was to be locked. On 3/20/23 at 2:16 PM this surveyor and Staff 2 (DNS) walked by a treatment cart at the nurse's station. The treatment cart was observed to be unlocked. There were no staff or residents near the treatment cart. The cart contained insulin, needles and creams. Staff 2 stated the cart was to be locked.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-24 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    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 laboratory services were obtained for 1 of 1 sampled resident (#2) reviewed for change of condition. This placed residents at risk for delayed treatment. Findings include: Resident 2 was admitted to the facility in 2022 with diagnoses including cognitive impairment. Progress Notes indicated on 12/8/22 Resident 2 had increased confusion, poor intake and a low grade fever. The resident's physician was notified and ordered a UA. On 12/10/22, Saturday, the facility staff called the laboratory to follow-up on the UA specimen pick-up. The note indicated the laboratory did not come to the facility on the weekends and a new UA would be collected on 12/11/22, Sunday, for an early 12/12/22, Monday, pick-up. On 3/21/23 at 3:25 PM Staff 2 (DNS) stated the facility used the local hospital laboratory and they only picked up samples Monday through Friday. Samples which were marked as urgent would be picked up on Saturday and Sunday. Staff 2 indicated on the weekend if a UA was not ordered as urgent the facility…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-24 · 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 ensure 5 of 5 sampled residents (#s 2, 3, 4, 11 and 114) were offered a PCV20 (pneumonia) vaccine. This placed residents at risk for respiratory infections. Findings include: 1. Resident 2 was admitted to the facility in 2022 with diagnoses including high blood pressure. Resident 2's record revealed she/he was not offered the PCV20 vaccine. On 3/23/23 at 1:30 PM Staff 2 (DNS) and Staff 3 (Operations Consultant RN) stated the resident was eligible but was not offered the PCV20 vaccine. 2. Resident 3 was readmitted to the facility in 2014 with diagnoses including adult failure to thrive. Resident 3's record revealed she/he was eligible but not offered the PCV20 vaccine. On 3/23/23 at 1:30 PM Staff 2 (DNS) and Staff 3 (Operations Consultant RN) stated the resident was eligible but was not offered the PCV20 vaccine. 3. Resident 4 was admitted to the facility in 2022 with diagnoses including stroke. Resident 4's record revealed she/he was eligible but was not offered the PCV20 vaccine. On 3/23/23 at 1:30 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.

    Infection Control 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

No federal fines in the current CMS record.

Part of a chain

This home belongs to HUMANGOOD — 17 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 5 of 54.5+0.5 vs chain
Health inspection 5 of 53.6+1.4 vs chain
Staffing 4 of 54.9-0.9 vs chain
Quality measures 4 of 54.2-0.2 vs chain
The other 16 homes this chain runs (chain average 4.5★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
HG HILLSIDE, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF100%since 04/13/2026
HUMANGOODOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 05/01/2023
HUMANGOOD CORNERSTONEOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 05/01/2023
WEST VALLEY NURSING HOMES INCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 05/01/2023
BAKER, JUDITHIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 05/01/2023
BATTISON, WILLIAMIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 05/01/2023
BROWN, HERMANIndividualMANAGING CONTROL - GOVERNING BODYsince 05/01/2023
COCHRANE, JOHNIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 05/01/2023
GHASSEMI, BETHANYIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 05/01/2023
GRIFFITH, ALANIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 06/30/2019
HOLMES, MICHELLEIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 05/01/2016
KELLEY, ALBERTIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 05/01/2016
MCDONALD, ANDREWIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 05/01/2023
OGUS, DANIELIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 05/01/2023
WILLIAMS, ROBERTIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 05/01/2023
CAMPBELL, HEATHERIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/28/2025
COOK, STEPHANIEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/13/2023
GONZALES, DEBORAHIndividualOPERATIONAL/MANAGERIAL CONTROLsince 05/01/2023
MOHR, LOGANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/14/2025
RUDEN, NATHANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2023
VANGELISTO, GWENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/30/2021
BAKER TILLY ADVISORY GROUP LPOrganizationADP OF THE SNFsince 03/21/2025
BAKER TILLY US LLPOrganizationADP OF THE SNFsince 10/15/2024
HANSEN HUNTER LLCOrganizationADP OF THE SNFsince 05/01/2023

CMS files one row per role, so the 44 rows in the source record cover these 24 parties — each is shown once here with every role it holds. Nothing is omitted.

7 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

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

$10.8M
Net patient revenuemost recent cost report
-21.1%
Operating marginrevenue minus expenses
$351K
Related-party expense3% of expenses

This home reported $351K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$183per resident / day
operating cost
$5,574per month
≈ monthly operating cost
$151per 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 385269. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-25, 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.

What to do next