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Rogue Valley Manor

1200 Mira Mar Avenue, Medford, OR 97504 · Non profit - Corporation · 68 certified beds · (541) 857-7777 Medicare only — no Medicaid

Call the home — (541) 857-7777 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent Apr 2024Resident-funds citation (F0565)Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0565)
  • a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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

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

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

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
781 Black Oak Dr · (541) 789-4236 · Call to confirm hours
Pharmacy
2825 E Barnett Rd · (541) 789-7000 · Call to confirm hours
Grocery
Ning-Nang0.7 mi
2233 S Pacific Hwy · (541) 840-5449 · Call to confirm hours
Park
Medford Sports Park · Typically dawn to dusk
Place of worship
815 Black Oak Dr

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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 increased29.0%14.9%15.4%worse
Long-stay residents who lose too much weight2.9%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 infection4.9%2.0%2.0%worse
Long-stay residents with depressive symptoms2.7%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 medication17.6%12.4%18.9%typical
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 control25.5%21.8%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table0.0%13.9%17.1%check this — see note marked star below the table
Short-stay residents who newly got an antipsychotic medication0.6%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine96.1%81.2%79.4%better
Short-stay residents rehospitalized after admission22.6%21.4%22.6%typical
Short-stay residents with an outpatient ER visit10.0%16.1%12.0%better

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

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

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

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

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

67.4% 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 214 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

67.4%U.S. median 51.5%
Got home and stayed home
8.3%U.S. median 10.7%
Went back to hospital
44.0%U.S. median 56.6%
Met the expected recovery
0.73U.S. median 0.31
Therapy hours / resident / day
0.50hours / resident / day
Physical therapy
0.21hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 44.0% 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 100 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 0.73 therapist hours per resident per day in 2026Q1 — more than 93% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 9% 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 SNF67.4%CMS range 61.4–71.951.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF8.3%CMS range 5.7–12.510.7%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 discharge44.0%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 discharge45.0%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 discharge35.0%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 identified98.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%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 worsened3.5%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 hospitalization5.3%CMS range 3.2–8.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.871.02Oct 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

1.59
RN hours/ resident / day
0.77
LPN hours/ resident / day
4.21
Aide hours/ resident / day
6.56
Total nurse hours/ resident / day
1.32
RN hoursweekends
42.1%
Total nursing turnover
46.7%
RN turnover

How full it usually is: this home is certified for 68 beds and averages 28.8 residents a day — about 42% occupied, or roughly 39 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 6.56 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.59 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 4.21 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 5.85 hrs/resident/day on weekends vs 6.85 on weekdays — 15% thinner on weekends. RN hours go from 1.69 to 1.32 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 42% is about the same as 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

6
deficiencies at the latest standard inspection (2025-04-24)
4
at the previous standard inspection (2024-04-05)

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.

17 citations, most serious first. The 10 most serious are shown; the remaining 7 are one tap away and print in full.

  • Potential for harm · Ecited before2025-04-24 · 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, interview and record review the facility failed to ensure food was properly stored and discarded in a timely manner, kitchen staff wore appropriate hair and beard restraints, and equipment was sanitized for 1 of 1 kitchen. This placed residents at risk for cross-contamination and food-borne illnesses. Findings include: 1. On 4/21/25 at approximately 12:25 PM an observation of the walk-in cooler revealed the following outdated food items: hoisin sauce expired 3/30/25, cooked peppers expired 4/20/25, cooked rice expired 4/13/25, beef base opened with no remove by date, and shredded cheese expired 4/18/25. On 4/24/25 at 8:20 AM Staff 20 (Cook) inspected the walk-in cooler and confirmed the out-dated items. 2. A review of the facility Dress Code effective 11/2024 revealed staff handling food shall wear hair restraints such as hats, hair covering, hair restraints, or clothing that covers body hair. On 4/21/25 at 3:59 PM two unidentified staff were observed working on the tray line and in the kitchen area without hair restraints. Additional staff were seen 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-24 · 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 — the official record, unedited, may be distressing

    Based on interview and record review it was determined the facility failed to offer residents the opportunity to participate in the care planning process for 1 of 5 sampled residents (#6) reviewed for unnecessary medications. This placed residents at risk for unmet needs. Findings include: Resident 6 was admitted to the facility in 11/2022 with diagnoses including diabetes. A review of the 2/16/25 BIMS assessment indicated a score of 13 (cognitively intact). On 4/21/25 at 5:16 PM Resident 6 stated she/he could not remember her/his last care conference. An 4/22/25 review of Resident 6's clincial record revealed a care conference was completed on 11/20/24. There was no indication any care conference was held between 11/20/24 and 4/22/25. On 4/24/25 at 10:49 AM Staff 2 (DNS) acknowledged a care conference had not been completed for Resident 6 since 11/2024 and stated the expectation was for care conferences to be completed quarterly for every resident.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-24 · tag F0565 — failed to support the resident council — isolated
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    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 effectively respond to resident council concerns expressed at 3 of 4 resident council meetings reviewed. This placed residents at risk for unaddressed concerns related to resident care and quality of life. Findings include: Resident 6 was admitted to the facility in 11/2022 with diagnoses including diabetes. A review of the 2/16/25 BIMS assessment for Resident 6 indicated a score of 13 (cognitively intact). Resident 7 was admitted to the facility in 6/2024 with diagnoses including history of falling. A review of the 3/20/25 BIMS assessment for Resident 7 indicated a score of 13 (cognitively intact). A 4/22/25 review of the 1/20/25, 2/28/25, 3/28/25, and 4/21/25 Resident Council Minutes revealed the following: - The 1/20/25 notes indicated Resident 7 requested more activities on the weekends because they were really boring and was acknowledged by Staff 1 (Administrator) and Staff 3 (Activities Director). - The 2/28/25 notes indicated Resident 6 stated she/he did not know what medications she/he was taking…

    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 · D2025-04-24 · 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 obtain information related to advance directives and health care decisions for 1 of 3 sampled residents (#177) reviewed for advance directives. This placed residents at risk for not having their health care decisions honored. Findings include: Resident 177 was admitted to the facility in 4/2025 with diagnoses including aftercare following surgery. Assembly Clinical Records policy dated 10/2022 indicated: Clinical records needing to be readily available for emergencies such as the POLST (Physician Orders for Life-Sustaining Treatment) and Advance Directive are maintained as hard copies. These records will be transported with the resident upon transfer to the emergency room and or hospital as required. A 4/4/25 Health Care admission Questionnaire indicated Resident 177 did not have an Advance Directive or a POLST. On 4/23/25 at 11:57 AM Staff 4 (RCM) stated upon admission to the facility she prepared a POLST in the admission paperwork so when the physician visits the resident they can review the POLST 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 · D2025-04-24 · 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

    Based on observation, interview, and record review it was determined the facility failed to provide meaningful activities for dependent residents for 1 of 1 sampled resident (#3) reviewed for activities. This placed residents at risk for lack of social interaction and isolation. Findings include: Resident 3 was admitted to the facility in 6/2012 with diagnoses including dementia and anxiety disorder. An 10/2023 facility Activity Program policy indicated a resident's activity plan was to be updated as the resident's needs changed, but no less than quarterly. The 7/5/24 Annual MDS revealed Resident 3 had a BIMS score of 2 (severe cognitive impairment). Resident 3 was dependent on staff for all cares and staff indicated she/he liked to listen to music, be around animals, and participate in group activities. An 10/4/24 revised care plan for activities indicated staff were to help Resident 3 listen to music and encourage observation of the bird feeder outside the resident's window. Staff were to provide one-on-one visits or activities if Resident 3 was unable to attend group events. An…

    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 before2025-04-24 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review it was determined the facility failed to ensure residents were free from unnecessary psychotropic medication for 1 of 5 sampled residents (#177) reviewed for unnecessary medication. This placed residents at risk for adverse side effects. Findings include: Resident 177 was admitted to the facility in 4/2025 with diagnoses including anxiety and sleep apnea (pause in breathing during sleep). Review of the clinical record on 4/22/25 revealed Resident 177 was ordered PRN Lorazepam (for anxiety) every six hours starting on 4/4/25. The Lorazepam was discontinued and restarted on 4/17/25 with no end date. Resident 177's 4/4/25 pharmacy review revealed the provider was advised PRN Lorazepam required the prescriber to provide a direct examination and rationale for continuing the medication beyond 14 days. An undated response from the physician indicated: Ensure above documentation requirements are met and on file for the medication to continue beyond 14 days. No other information was provided. On 4/24/25 at 10:31 AM Staff 1 (Administrator)…

    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 · Ecited before2024-04-05 · 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 ensure refrigerators were free of expired and/or unlabeled foods for 1 of 2 refrigerators reviewed for food safety and sanitation. This placed residents at risk for food-borne illness. Findings include: On 4/4/24 at 2:07 PM the following was observed in refrigerator number two: - cooked eggs in a clear container dated 3/31/24. - cut strawberries in a disposable plastic container with no date. - 13 Thirster grape concentrate 100% grape juice containers marked, Best by 10/14/23. On 4/04/24 at 2:17 PM Staff 10 (Dietary manager) confirmed the thirster, strawberries, and prepped eggs were not appropriately labeled or discarded.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-05 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    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 investigate an injury of unknown source for 1 of 4 sampled residents (#20) reviewed for pressure ulcers. This placed residents at risk for injury. Findings include: Resident 20 was admitted to the facility in 2023 with diagnoses including dementia and stroke. A 3/25/24 hospice note identified new large bruises to both shins, greater on the right leg. A 3/25/24 Skin and Wound Evaluation noted a new skin tear to Resident 20's right shin in the same area as the large bruise. The wound was measured to be approximately 25 cm long by six cm wide, there was missing skin and the wound was bleeding. The conclusion included in the evaluation indicated Resident 20 attempted to get out of bed and got her/his leg caught between the bed and the side rail. A 3/27/24 hospice note acknowledged the new skin tear to Resident 20's right shin, and very fragile bruised skin. On 4/2/24 at 4:14 PM Resident 20 was observed in bed with her/his feet elevated off the mattress and the bed was in a low position. There were…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-05 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — the official record, unedited, 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 revise a care plan timely related to catheter use for 1 of 4 sampled residents (#20) reviewed for pressure ulcers. This placed residents at risk for unmet catheter needs. Findings include: Resident 20 was admitted to the facility in 2023 with diagnoses including dementia and stroke. An admission MDS dated [DATE] indicated Resident 20 was occasionally incontinent of bowel and bladder. On 12/7/23 resident records indicated Resident 20 was unable to empty her/his bladder and a catheter was placed. Resident 20's care plan was revised on 4/2/24 to include the catheter use. On 4/5/24 at 10:40 AM Staff 5 (LPN/MDS Coordinator) acknowledged Resident 20's care plan was not revised timely.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-05 · 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 observation, interview and record review it was determined the facility failed to thoroughly assess pressure ulcers for 2 of 4 sampled residents (#s 20 and 88) reviewed for pressure ulcers. This placed residents at risk for unmanaged wounds. Findings include: 1. Resident 20 was admitted to the facility in 2023 with diagnoses including dementia, stroke and on hospice services. A hospice note dated 3/21/24 indicated Resident 20 had a closed purple pressure injury/ulcer on her/his right heel. A hospice note dated 3/25/24 indicated Resident 20 had new right heel eschar (dead tissue that is usually dark, dry and hard) with a closed blister in the middle. The note added a facility nurse took a picture of the wound. A Skin and Wound Evaluation dated 3/25/24 identified a new blister to Resident 20's right heel. The wound was described as intact and black/blue in color. There were no measurements of the wound. An Incident Report dated 3/25/24 indicated the facility nurse was notified by hospice of a new DTI…

    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 7 citations
  • Potential for harm · E2023-01-27 · 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 provide a homelike dining experience for 1 of 2 dining rooms reviewed for dining. This placed residents at risk for a non-homelike environment. Findings include: On 1/24/23 at 10:43 AM Resident 24 stated she/he did not like to go to the assisted dining room for meals because the dining room was sad. On 1/24/23 at 12:20 PM lunch was observed in the assisted dining room. In the middle of the dining room there was a long table without linen, a centerpiece or decorations on it. The walls were bare except for a large projection screen on one wall with nothing projected on it. Multiple chairs were observed against the same wall. The plates were served on the trays. There were four residents observed eating lunch in silence, a CNA sat between two residents assisting with their meals. The CNA did not talk to the residents. On 1/25/23 at 8:06 AM breakfast was observed in the assisted dining room. A CNA was observed to be looking at her phone. Breakfast was served to the residents with their plates on the trays 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 · E2023-01-27 · tag F0609 — failed to report abuse allegations — pattern
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to report allegations of abuse and misappropriation of property for 3 of 3 sampled residents (#s 12, 129 and 130) reviewed for injuries of unknown origin and misappropriation of personal property. This placed residents at risk for abuse. Findings include: 1. A public Complaint was received on 12/21/21 which alleged there were at least two residents (#s 129 and 130) with missing narcotic medications. On 1/27/23 at 8:45 AM Staff 1 (Administrator) indicated the facility confirmed 63 tablets of narcotic medication were missing, 48 tablets of oxycodone for Resident 129 and 30 (1/2 tablets) of oxycodone for Resident 130. The facility was not able to identify a suspect but identified significant gaps in their processes as well as areas where they needed improvement. Staff 1 indicated she did not receive information on the missing medication until 12/20/21 although the DNS was notified on 12/12/21. A copy of a FRI Report dated 1/25/22 at 9:00 AM was provided by Staff 1. In a description of the incidents of missing…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-01-27 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to ensure residents were free of unnecessary psychotropic (affects brain activities) medications for 5 of 7 sampled residents (#s 12, 14, 16, 21 and 23) reviewed for hospice, medications and mood and behavior. This placed residents at risk for receiving unnecessary psychotropic medications. Findings include: 1. Resident 21 was readmitted to the facility in 2022 for end of life care and dementia. A Hospice Provider note dated 8/3/22 indicated prescribed psychotropic medication was required for more than 14 days for resident comfort in a hospice setting. The note further indicated Resident 21 required the medication on a PRN basis for optimal symptom management and safety. Additionally, anxiety, agitation or trouble breathing could be anticipated and the resident would suffer unnecessarily if a new order and face to face visit were required once end of life symptoms acutely developed. The 1/2022 MAR indicated Resident 21 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-01-27 · 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 — the official record, unedited, may be distressing

    Based on interview and record review it was determined the facility failed to ensure influenza vaccinations were administered for 3 of 5 sampled residents (#s 10, 13 and 17) reviewed for immunizations. This placed residents at risk for influenza. Findings include: The 2022 CDC Recommended Adult Immunization Schedule recommended administration of the influenza vaccine annually. Resident 17 was admitted to the facility in 2020. A review of Resident 17's immunizations revealed no documentation the 2022 influenza vaccination was offered, refused or administered. Resident 10 was admitted to the facility in 2018. A review of Resident 10's immunizations revealed no documentation the 2022 influenza vaccination was offered, refused or administered. Resident 13 was admitted to the facility in 2021. A review of Resident 13's immunizations revealed no documentation the 2022 influenza vaccination was offered, refused or administered. On 1/26/23 at 12:07 PM Staff 2 (DNS) confirmed Resident 17, Resident 10, and Resident 13 were not offered and did not refuse or receive the influenza vaccine.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-27 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review it was determined the facility failed to revise care plans for 1 of 2 sampled resident (#24) reviewed for ADLs. This placed residents at risk for unmet needs. Findings include: Resident 24 admitted to facility in 12/2022 with diagnoses including malnutrition and dehydration. A 1/9/23 Significant Change MDS revealed Resident 24 required limited assistance with eating. A review of Resident 24's physician orders revealed: - 12/21/22 orders for SLP evaluation and treatment due to coughing with food and fluids - 12/26/22 orders for a mechanical soft diet (chopped and ground foods) with nectar thick fluids (fluid with the consistency comparable to heavy syrup found in canned fruit) per SLP recommendations - 12/29/22 orders for one-to-one feeding On 1/24/23 at 12:20 PM Resident 24 was observed eating lunch in the assisted dining room with staff present but without staff cues for safe eating. A 1/24/23 Speech Therapy progress note revealed the speech therapist created a Swallow Recommendation sign for Resident 24. A review of Resident 24'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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-27 · 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 follow the baseline care plan for 1 of 1 sampled resident (#179) reviewed for nutrition. This placed residents at risk for unmet needs. Findings include: Resident 179 was admitted to the facility in 1/2023 with diagnoses including dysphagia (swallowing difficulties). A 1/16/23 baseline care plan revealed Resident 179 had a swallowing problem and required supervision for meals. On 1/25/23 Staff 5 (CNA) set up Resident 179's meal in her/his room on the overbed table, encouraged Resident 179 to eat and left the room. On 1/25/23 at 8:00 AM Staff 5 stated she was not sure about Resident 179's needs, but mainly she/he ate alone when her/his spouse was not there. Staff 5 stated Resident 179 did not want to go to the dining room for breakfast. Staff 5 stated she checked on Resident 179 frequently. On 1/25/23 at 8:07 AM Resident 179 was alone in her/his room, the breakfast food tray was on the overbed table in front of her/him and she/he was chewing food. On 1/25/23 at 8:14 AM Staff 4 (RNCM) stated…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-27 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to follow up on pharmacy recommendations for 1 of 6 sampled residents (#12) reviewed for medications. This place residents at risk for unnecessary medications. Findings include: Resident 12 was admitted to the facility in 2022 with diagnoses including stroke. Medical records indicated Resident 12 had an order for mirtazepine (antidepressant) for insomnia. The admission MDS dated [DATE] indicated Resident 12 was taking mirtazepine for depression. A 12/17/22 Consultant Pharmacist's Medication Regimen Review noted the use of mirtazepine for insomnia. The review also indicated facility staff did not feel Resident 12 had trouble with insomnia. The Consultant Pharmacist recommended discontinuation of mirtazepine. A 1/16/23 Consultant Pharmacist's Medication Regimen Review indicated Resident 12 started mirtazepine originally as an appetite stimulant. Resident 12 currently had a feeding tube and was not having insomnia. The Consultant Pharmacist…

    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

“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 PACIFIC RETIREMENT SERVICES — 10 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 54.6+0.4 vs chain
Health inspection 4 of 54.3-0.3 vs chain
Staffing 5 of 54.7+0.3 vs chain
Quality measures 3 of 54.1-1.1 vs chain
The other 9 homes this chain runs (chain average 4.6★, 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 / managerTypeRoleSince
US BANK NATIONAL ASSOCIATIONOrganization5% OR GREATER SECURITY INTERESTsince 12/01/2007
SOLMONSON, STANIndividualW-2 MANAGING EMPLOYEE; CORPORATE DIRECTORsince 04/13/2020
BEATTIE, JULIEIndividualCORPORATE DIRECTORsince 01/10/2022
BHASIN, ANIRUDHIndividualCORPORATE DIRECTORsince 10/01/2015
BROPHY, TIMOTHYIndividualCORPORATE DIRECTORsince 07/12/2021
CHRISTLIEB, CARLIndividualCORPORATE DIRECTORsince 04/15/2013
HEYSELL, RUSSELLIndividualCORPORATE DIRECTORsince 04/15/2014
JACOBS, WILLIAMIndividualCORPORATE DIRECTORsince 10/01/2019
MAYERS, ROBERTIndividualCORPORATE DIRECTORsince 04/15/2013
SEVICK, APRILIndividualCORPORATE DIRECTORsince 04/15/2013
WILLMS, FREDRICIndividualCORPORATE DIRECTORsince 04/15/2013
SHOLTY, ERICIndividualCORPORATE OFFICERsince 05/27/2018
PACIFIC RETIREMENT SERVICES INCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 10/01/1996

CMS files one row per role, so the 14 rows in the source record cover these 13 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.

2 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.

$44.0M
Net patient revenuemost recent cost report
-46.3%
Operating marginrevenue minus expenses
$3.3M
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 0%Medicare 5%Other / private 95%

This home reported $3.3M 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

$1,294per resident / day
operating cost
$39,345per month
≈ monthly operating cost
$885per 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

CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the Oregon Medicaid page for homes that do.

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 385250. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-24, 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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