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Mt Angel Health And Rehabilitation

540 South Main Street, Mount Angel, OR 97362 · For profit - Corporation · 93 certified beds · (503) 845-6841 Medicare & Medicaid certified

Call the home — (503) 845-6841 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citations on record (F0600, F0602) — most recent Jun 20252 actual-harm citations$27,967 in federal fines
Insights

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

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)
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Jun 2025
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $27,967 in federal fines (most recent 2024-09-19)
  • nursing-staff turnover (60%) 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.

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

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
410 Welch St · (503) 873-5331 · Call to confirm hours
Pharmacy
105 N Main St · (503) 845-6133 · Call to confirm hours
Grocery
14433 Marquam Rd NE · (503) 845-6822 · Call to confirm hours
Park
501 May 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 4 of 5
Short-stay residentsrehab / post-hospital 4 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased16.3%14.9%15.4%typical
Long-stay residents who lose too much weight2.6%4.7%5.4%better
Long-stay residents with a catheter left in their bladder0.4%1.4%0.9%better
Long-stay residents with a urinary tract infection1.3%2.0%2.0%better
Long-stay residents with depressive symptoms11.0%4.9%6.5%worse
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.3%2.4%3.3%better
Long-stay residents whose ability to walk worsened17.5%20.6%16.1%typical
Long-stay residents on antianxiety or hypnotic medication21.8%12.4%18.9%worse
Long-stay residents given the seasonal flu vaccine90.3%95.2%95.3%typical
Long-stay residents with pressure ulcers3.7%5.8%4.7%better
Long-stay residents with worsening bladder/bowel control20.3%21.8%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table18.5%13.9%17.1%typical
Short-stay residents who newly got an antipsychotic medication1.7%1.4%1.4%worse
Short-stay residents given the seasonal flu vaccine72.4%81.2%79.4%typical
Short-stay residents rehospitalized after admission15.9%21.4%22.6%better
Short-stay residents with an outpatient ER visit14.7%16.1%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.261.481.67worse
Long-stay outpatient ER visits per 1,000 resident days1.532.351.80better

§ 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.

60.6% 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 103 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

60.6%U.S. median 51.5%
Got home and stayed home
11.2%U.S. median 10.7%
Went back to hospital
53.7%U.S. median 56.6%
Met the expected recovery
0.55U.S. median 0.31
Therapy hours / resident / day
0.31hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy
0.11hours / resident / day
Speech therapy

Met the expected recovery: 53.7% 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 67 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 0.55 therapist hours per resident per day in 2026Q1 — more than 85% 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 SNF60.6%CMS range 51.7–70.051.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.2%CMS range 7.8–15.610.7%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 discharge53.7%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 discharge41.8%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 discharge43.3%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 identified92.1%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 setting100.0%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 discharge96.3%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 stay1.3%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 worsened4.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.0%CMS range 2.9–11.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.771.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.76
RN hours/ resident / day
0.97
LPN hours/ resident / day
3.51
Aide hours/ resident / day
5.23
Total nurse hours/ resident / day
0.51
RN hoursweekends
60.4%
Total nursing turnover
74.2%
RN turnover

How full it usually is: this home is certified for 93 beds and averages 74.0 residents a day — about 80% occupied, or roughly 19 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 5.23 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.76 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.51 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.68 hrs/resident/day on weekends vs 5.45 on weekdays — 14% thinner on weekends. RN hours go from 0.86 to 0.51 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 60% is well above the national median of 45%.

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

Inspection trend

5
deficiencies at the latest standard inspection (2026-06-05)
2
at the previous standard inspection (2025-02-14)

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.

22 citations, most serious first. The 12 most serious are shown; the remaining 10 are one tap away and print in full.

  • Actual harm · G2024-09-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to prevent an avoidable fall related to fall safety for 1 of 3 sampled residents (#1) reviewed for accidents. Resident 1 fell out of bed and sustained a right shoulder fracture. Findings include: Resident 1 was admitted to the facility in 7/2024 with diagnoses including quadriplegia (paralysis that affects all a person's limbs and body from the neck down) and a Stage 4 (full thickness skin loss) pressure injury. The admission MDS dated [DATE], revealed Resident 1 was cognitively intact. A care plan dated 7/25/24, revealed Resident 1 was limited in performing ADLs and was encouraged to perform as much of her/his ADLs as their condition allowed. Staff were to follow the most recent instructions and posted wall signs for mobility, transfers, exercises, and restorative programs. A revision on 7/27/24, revealed Resident 1 had half siderails on both sides of her/his bed to assist with repositioning and bed mobility. Two undated bedside care plans revealed the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2024-04-03 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review it was determined the facility failed to protect the resident's right to be free from sexual abuse by another resident for 1 of 2 sampled residents (#1) reviewed for sexual abuse. This resulted in Resident 1 experiencing psychosocial harm and increased distress. Findings include: Resident 1 was admitted to the facility in 3/2024 with diagnoses including dementia, mood disturbance, anxiety and developmental disorder of speech and language. A 3/22/24 Cognitive Loss and Dementia CAA revealed Resident 1 required one-step cueing for tasks, time to process cues and communication, and 24-hour supervision for safety. Resident 1 required a floor alarm because the resident did not remember to use the call light. Staff were to provide simple direct communication and interpret Resident 1's tone of voice and facial expressions. Resident 2 was admitted to the facility in 3/2024 with diagnoses including stroke and encephalopathy (damage or disease that affects the brain). Resident 2's care plan, initiated on 3/26/24, revealed Resident 2 had a…

    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 · E2026-06-05 · tag F0730 — pattern
    Observe each nurse aide's job performance and give regular training.
    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 CNA staff annual performance reviews were completed for 3 of 3 sampled CNA staff (#s 11, 12, 23) reviewed for sufficient and competent nurse staffing. This placed residents at risk for a lack of competent staff. Findings include: A review of personnel records on 6/5/26 indicated the following employees did not receive their annual performance evaluations: -Staff 11 (CNA), hire date was 12/2019 and a performance review was not completed.-Staff 12 (CNA), hire date was 8/2013 and a performance review was not completed.-Staff 13 (CNA), hire date was 1/2019 and a performance review was not completed. On 6/4/26 at 4:00 PM, Staff 1 (Administrator) and Staff 2 (DNS) confirmed annual performance reviews were not completed for Staff 11, Staff 12 and Staff 13.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-06-05 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review it was determined the facility failed to properly disinfect a shared glucometer for 1 of 3 facility staff (#5) reviewed for infection control. This placed residents at risk for exposure to blood-borne pathogens. Findings include: The 12/2025 facility Glucometer Disinfection Policy indicated to disinfect after each individual patient use with EPA disinfectant wipes. A 2017 Evencare G2 glucometer Manufacturer Manual indicated, Disinfect common use glucometers with the use of approved disinfectant wipes. The glucometer was to be wiped with the disinfecting wipe and left wet for two minutes to ensure disinfection. Resident 81 was admitted to the facility in 11/2025 with diagnoses including diabetes.On 6/3/26 at 11:33 AM, Staff 5 (LPN Resident Care Manager) was observed to return to the medication cart after checking Resident 81's CBG, and place the glucometer in the drawer. Staff 5 did not disinfect the glucometer. On 6/3/26 at 11:51 AM, Staff 5 stated she used alcohol pad wipes to clean the glucometers after she checked residents CBG.…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-05 · 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 — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility to revise a resident's care plan for 1 of 1 sampled resident (#3) reviewed for hospice. This placed residents at risk for unmet hospice needs. Findings include: Resident 3 was admitted to the facility 2024 with diagnoses including dementia, bipolar and heart failure.The 8/14/25 Significant Change MDS indicated Resident 3 was on hospice status.Review of Resident 3's care plan referred to hospice and/or end of life in the following manner:-For ADL care hospice helped with bathing, dated 2/13/26. -For psychosocial well-being hospice was identified as one service to provide consultation, date initiated 7/3/25. -For activities, hospice was identified and indicated the resident often declined, date initiated 2/19/26. -Use of anti-anxiety medication related to end of life, dated 9/12/25. The Care Plan did not indicate Resident 3's terminal illness as a focus area with interventions including hospice services or interventions related to end of life.On 6/4/26 at 9:30 AM Staff 2 (DNS) stated her expectation was for a terminal…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-05 · 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 was determined the facility failed to implement bowel care interventions for 2 of 5 sampled residents (#s 12 and 19) reviewed for medications. This placed residents at risk for constipation. Findings include: 1. Resident 12 admitted to the facility in 2025 with diagnoses including chronic pain and heart failure. The facility's revised 3/31/26 bowel care policy indicated the following for patients not on a daily senna bowel medication: -If no BM in two days, Miralax was to be given. -If no BM on day three, Miralax was to be repeated, and provider was to be notified. -If no BM on day four, suppository was to be administered, and provider was to be notified. -Results from all treatment were to be monitored and recorded. Review of Resident 12's 5/26/26 physician orders indicated the following bowel medications: -Lactulose as needed for constipation -Bisacodyl suppository as needed for constipation -Milk of Magnesia as needed for constipation -Docusate as needed for constipation -Senna as needed for constipation -Miralax as needed for no BM in 2…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-05 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review it was determined the facility failed to provide services to prevent further decrease in ROM for 1 of 2 sampled residents (#17) reviewed for positioning. This placed residents at risk for decrease in range of motion. Findings include:Resident 17 was admitted to the facility in 2/2018 with diagnoses including osteomyelitis (inflammation in the bones).The 2/18/26 Quarterly MDS indicated the resident had a BIMS score of 00 indicating Resident 17 was severely cognitively impaired. The MDS indicated Resident 17 was unable to make daily decisions and was dependent on staff to complete daily activities including to apply splints. The MDS indicated Resident 17 had bilateral upper and lower ROM impairments. The 3/19/26 Care Plan indicated Resident 17 wore a left-hand carrot splint and a right-hand palm guard. During interviews on 6/3/26 at 11:24 AM and 6/4/26 at 10:56 AM, Resident 17's hands were observed to be curled up into a fist. Resident 17 was unable to extend her hand. Resident 17 was not wearing her/his hand splint and the splint was…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-20 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to protect residents' right to be free from misappropriation of property by staff for 1 of 1 sampled resident (#4) reviewed for misappropriation of property. This placed residents at risk for financial loss. Findings include: Resident 4 admitted to the facility in 3/2024 with diagnoses including diabetes. A 5/22/25 Facility Reported Incident revealed Resident 4 was admitted to the hospital on [DATE] and passed away at the hospital on 5/21/25. On 5/21/25 Staff 7 (RN) locked up Resident 4's personal belongings including credit cards and debit cards in the narcotic box in the medication cart. On 5/22/25 Staff 7 discovered Resident 4's credit and debit cards were no longer in the medication cart. A 5/29/25 Investigation Report revealed: -Staff 7 wrapped Resident 4's six bank, credit, and debit cards in a piece of notepad paper and placed them in the very back of the narcotic lock box on 5/21/25. -Staff 6 (Former LPN) replaced Staff 7 at 4:00…

    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 · Past Non-Compliance
  • Potential for harm · Dcited before2025-02-14 · 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 was determined the facility failed to ensure physician orders were followed for 1 of 6 sampled residents (#10) reviewed for medications. This placed residents at risk for adverse medication side effects. Findings include: Resident 10 readmitted to the facility in 2023 with diagnoses including dementia and schizoaffective disorder. a. The 3/6/24 medication error investigation indicated the following: -On 3/6/24 at 4:32 PM Staff 14 (RN) administered the following medications (in error) to Resident Resident 10: -clonazepam 0.5 mg (anticonvulsant medication) -Depakote 200 mg (anticonvulsant medication) -docusate sodium 100 mg (bowel medication) -gabapentin 400 mg (mood stabilizer medication) -metoprolol 12.5 mg (blood pressure medication) -levothyroxine 200 mcg (thyroid medication) -clozapine 100 mg (antipsychotic medication) On 3/6/24 the physician was notified of the medication error. On 2/13/25 at 10:18 AM Staff 14 stated she worked on 3/6/24. She stated she prepared another resident's medications and administered them to Resident 10 by…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-19 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to identify and reflect risk factors in the care plan related to pressure ulcers for 1 of 3 sampled residents (#2) reviewed for pressure ulcers. This placed residents at risk for pressure injuries and skin breakdown. Findings include: Resident 2 admitted to the facility in 8/2023 with diagnoses including a colostomy (redirects the colon to an opening in the abdominal wall, called a stoma, which is attached to a colostomy bag to collect bowel movements) and cellulitis of the abdomen. The admission MDS dated [DATE], revealed Resident 2 was cognitively intact. A care plan dated 8/8/23, revealed Resident 2 had a colostomy, impaired skin integrity, a wound around the stoma, nonhealing skin graft to the buttocks, and history of pressure injury. Staff were to monitor the ostomy appliance and belt for moisture and tightness twice daily, encourage the resident to loosen her/his belt when lying down, and monitor for signs and symptoms of infection.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-22 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to ensure a resident was free from verbal abuse for a resident-to-resident altercation for 1 of 4 sampled residents (#8) reviewed for abuse. This placed residents at risk for isolation. Findings include: Resident 8 admitted to the facility in 2021 with diagnoses including depression. Resident 6 admitted to the facility in 2022 with diagnoses including bipolar and personality disorder. On 11/29/23 a facility investigation indicated an incident of resident-to-resident verbal abuse. Resident 6 came out of her/his room into the common area after Resident 8 arrived for breakfast. Resident 6 directed her/his attention to Resident 8 and stated, It stinks in here. Resident 8 stated it was not nice to make the statement and Resident 6 responded, Who cares? A verbal argument developed, and staff intervened. However, Resident 6 continued to make unpleasant comments to Resident 8. Resident 8 indicated Resident 6 made comments in the past which led Resident 8 to isolate in her/his room. Verbal abuse was substantiated by…

    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 before2024-03-22 · 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 — 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 ensure physician orders were followed for 1 of 3 sampled residents (#3) reviewed for medication administration. This placed residents at risk for adverse side effects of medications. Findings include: Resident 3 admitted to the facility on [DATE] with diagnoses including femur fracture. The 11/27/23 physician orders indicated Resident 3 was to receive aspirin 81 mg BID for 23 days (until 12/19/23) and then stop. The 11/2023 and 12/2023 MARs indicated Resident 3 received aspirin once daily from 11/28/23 through 12/8/23. The 12/8/23 physician order indicated to discontinue aspirin. On 3/22/24 at 9:15 AM Staff 2 (DNS) acknowledged Resident 3 did not receive aspirin as ordered from 11/28/23 through 12/8/23.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 10 citations
  • Potential for harm · F2023-09-22 · tag F0842 — failed to keep accurate, complete medical records — widespread
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review it was determined the facility failed to protect resident identifiable information and ensure resident records were accurate for 1 of 1 facility and for 1 of 2 sampled residents (#466) reviewed for record management and insulin. This placed residents at risk for unauthorized use of their personal information and inaccurate medical records. Findings include: 1. A review of the facility's undated Safeguarding Resident Identifiable Information policy indicated the facility was to adhere to HIPAA (Health Insurance Portability and Accountability Act) compliant practices by placing any printed material with residents' personal or medical information in a secure disposal container to be shredded. On 9/21/23 at 11:31 AM resident identifiable information including resident name, room number, discharge date and those who were on hospice care, was observed inside recycle bins located outside of the facility next to the garbage compactor. This list also indicated certain residents who had requested their identifiable information not 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-09-22 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined the facility failed to ensure resident rooms, bathrooms, ceiling fans, toilets/commodes and floor mats were sanitized and cleaned timely for 10 of 11 sampled residents (#s 3, 24, 27, 32, 35, 40, 46, 47, 51 and 52) and 2 of 4 halls (Harmony and Cedar) reviewed for environment. This placed residents at risk for an unsanitary environment. Findings include: On 9/18/23 and 9/19/23 the following observations were made: -room [ROOM NUMBER]: The resident stated she/he used the bathroom and stated she/he was unsure when it was last cleaned. The bathroom was observed to have black splatters across the inside of the bowl and on the back of the toilet seat. -room [ROOM NUMBER]: The resident stated she/he used the bathroom and shared it with residents in room [ROOM NUMBER] who also both used the bathroom. Resident 47 stated she/he was not sure how often the bathroom was cleaned. The toilet was observed to have black residue, dust, and debris around the back of the seat.…

    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 · D2023-09-22 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    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 treated residents with dignity and respect for 1 of 1 sampled resident (#56) reviewed for abuse. This placed residents at risk for lack of dignity. Findings include: Resident 56 was admitted to the facility in 4/2023 with chronic kidney disease. A 5/1/23 FRI revealed Staff 16 (CNA) told Resident 56 to shut up while assisting with ADL care. On 9/18/23 at 11:10 AM Resident 56 stated she/he did not recall the incident. On 9/20/23 at 5:33 PM Staff 16 stated she was assisting Resident 56 with ADLs and became frustrated. Staff 16 stated she told Resident 56 to shut up and immediately apologized for her mistake. On 9/21/23 at 3:14 PM Staff 2 (DNS) acknowledged the incident occurred and described it as a mistake. The findings were determined to be Past Noncompliance, as the facility identified and corrected the deficient practice prior to the survey. The deficient practice was corrected on 5/6/23 when the plan of corrected was fully implemented. The Plan of Correction included: 1. A facility incident…

    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 · Past Non-Compliance
  • Potential for harm · D2023-09-22 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review it was determined the facility failed to implement a person-centered care plan for 1 of 1 sampled resident (#21) reviewed for foot care. This placed residents at risk for skin breakdown. Findings include: 1. Resident 21 admitted to the facility in 12/2022 with diagnoses including peripheral vascular disease (blood circulation disorder) and chronic heart failure. Resident 21's care plan, initiated on 12/19/22, identified the resident was at risk for skin breakdown related to peripheral vascular disease, respiratory failure and local edema. Staff were to offload Resident 21's heels when in bed. On 9/20/23 at 9:52 AM Resident 21 stated she/he preferred to stay in bed and staff did not always place pillows under her/his feet. On 9/20/23 and 9/21/23 random observations revealed Resident 21's heels were not offloaded while in bed. On 9/21/23 at 10:45 AM Staff 14 (CNA) acknowledged Resident 21's heels were not offloaded and her/his heels were to be offloaded while the resident was in bed. Staff 14 stated staff were expected to follow the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-22 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to provide care and services to maintain good grooming and personal hygiene for 2 of 7 sampled residents (#s 21 and 41) reviewed for ADLs. This placed residents at risk for skin breakdown and quality of care. Findings include: 1. Resident 21 admitted to the facility in 12/2022 with diagnoses including peripheral vascular disease (blood circulation disorder) and chronic heart failure. Resident 21's care plan, initiated on 12/19/22, identified the resident was at risk for skin breakdown related to peripheral vascular disease, respiratory failure and local edema. The care plan indicated staff were to apply dressings, creams, or ointments as prescribed. Resident 21's 9/2023 TARs revealed Aquaphor (a thick ointment effective at protecting dry skin) was to be applied to Resident 21's lower leg extremities twice daily. On 9/20/23 at 9:52 AM Resident 21 stated staff applied lotion to her/his legs but had not applied lotion to her/his…

    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 · D2023-09-22 · tag F0687 — failed to care for feet properly — isolated
    Provide appropriate foot care.
    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 appropriate foot care for 1 of 1 sampled resident (#21) reviewed for foot care. This placed residents at risk for lack of nail care and infections. Findings include: Resident 21 admitted to the facility in 12/2022 with diagnoses including peripheral vascular disease (blood circulation disorder) and chronic heart failure. Resident 21's 9/2023 TAR revealed nail care was provided every week on Saturdays on her/his scheduled shower days. Staff initialed they provided weekly nail care on 9/2/23, 9/9/23 and 9/16/23. On 9/20/23 at 9:52 AM Resident 21 stated she/he requested an appointment in 7/2023 to have her/his toenails trimmed because the facility did not provide toenail care. Resident 21 stated the left toenails were a concern because the second toenail on her/his left foot was pressing into the left big toe and was kind of uncomfortable. On 9/20/23 at 9:55 AM Resident 21's toes were observed with all toenails discolored, deformed, thickened (half-an-inch) and longer than one inch.…

    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 · D2023-09-22 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review it was determined the facility failed to provide an emergency kit in the resident's for 1 of 1 sampled resident (#317) reviewed for dialysis. This placed the resident at risk for complications related to dialysis. Findings include: Resident 317 admitted to the facility in 8/2023 with diagnoses including end stage renal disease and diabetes. Resident 317's 9/4/23 admission MDS indicated the resident was cognitively intact. Resident 317's 9/9/23 admission Care Plan revealed the resident received dialysis (a procedure to remove waste products from the blood when the kidneys stop working) three times a week at a clinic outside the facility. On 9/20/23 at 9:46 AM observations made in Resident 317's room revealed no emergency kit in the room. On 9/21/23 at 10:00 AM Staff 22 (CNA) stated he would call the nurse if he noticed any bleeding from the resident's dialysis site. Staff 22 was unable to locate dressings, bandages or an emergency supply kit in the room if needed for an emergency. On 9/21/23 at 10:14 AM Staff 23 (Agency LPN) stated in…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-22 · tag F0725 — failed to have enough nursing staff — isolated
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide sufficient nursing staff to ensure call lights were answered timely for 3 of 4 sampled residents (#s 21, 53 and 466) and 2 of 4 halls (Harmony and Cedar) reviewed for call light wait times and staffing. This placed residents at risk for delays in treatment and lessened quality of care. Findings include: Interviews with residents revealed the following concerns: -On 9/18/23 at 10:40 AM Resident 53 stated staffing was a issues on all shifts and she/he sat in a wet and soiled brief for greater than 30 minutes because staff were unable to answer call lights. Resident 53 stated this occurred once every other month. -On 9/18/23 at 11:29 AM Resident 466 stated she/he needed assistance for toileting and call lights were long and she/he was a pretty patient person but if she/he did not receive help in the morning it was difficult to receive assistance timely. Random observations of call light response times: -9/20/23 at 8:25 AM Resident 21'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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-22 · 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 pharmacy recommendations in a timely manner for 1 of 5 sampled residents (#53) reviewed for unnecessary medications. This placed residents at risk for unnecessary medication administration. Findings include: Resident 53 admitted to the facility in 2/2023 with diagnoses including diabetes and congestive heart failure. Review of Resident 53's pharmacy recommendations revealed the following: -6/27/23 recommendation to consider adding GPL-1 (diabetic medication to improve blood sugar and assist in weight loss) and SGLT2 (medication to lower blood sugar) related to Resident 53's diagnoses of obesity, diabetes, chronic kidney disease, heart failure and A-fib. - 7/6/23 recommendation for a GDR for venlafaxine 75 mg taken daily (started 2/14/23). The recommendations were not signed by Resident 53's provider until 8/3/23. The provider indicated to start Jardiance daily (diabetic medication), Ozempic (GPL-1 medication) for seven days and to check labs in a month. A GDR for the Venlafaxine was declined due to…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2025-02-14 · tag F0625 — pattern
    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 residents with a written bed hold notification at the time of transfer to the hospital for 2 of 2 sampled residents (#s 30 and 38) reviewed for hospitalization. This placed residents at risk for lack of knowledge regarding their choices and potential financial responsibilities. Findings include: 1. Resident 30 was admitted to the facility in 1/2023 with diagnoses including depression and diabetes. A review of Resident 30's health record revealed she/he was discharged to the hospital on three separate occasions: 3/19/24, 4/22/24, and 7/8/24. No evidence was found in Resident 30's health record to indicate written notice of the facility's bed hold policy was provided to the resident or her/his representative when she/he was transferred to the hospital on 3/19/24, 4/22/24, and 7/8/24. On 2/13/25 at 3:50 PM Staff 2 (DNS) confirmed a written bed hold policy was not provided to Resident 30 or their representative when the resident was transferred to the hospital on the identified dates. 2. Resident 38…

    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

“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

$27,967 in federal fines across 2 penalties.

  • $10,033 — penalty dated 2024-09-19
  • $17,934 — penalty dated 2024-03-22

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

Part of a chain

This home belongs to THE ENSIGN GROUP — 342 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 4 of 53.2+0.8 vs chain
Health inspection 4 of 52.8+1.2 vs chain
Staffing 4 of 52.7+1.3 vs chain
Quality measures 4 of 54.4-0.4 vs chain
The other 341 homes this chain runs (chain average 3.2★, per CMS)
1 of 5Aspen Health And WellnessOverland Park, KS 1 of 5Bennett Hills Rehabilitation and Care CenterGooding, ID 1 of 5Broadway By The SeaLong Beach, CA 1 of 5Chatsworth Park Health Care CenterChatsworth, CA 1 of 5Clarion Wellness and Rehabilitation CenterClarion, IA 1 of 5Colonial Manor of RandolphRandolph, NE 1 of 5Durango Health And RehabilitationDurango, CO 1 of 5Fort Dodge Health and RehabilitationFort Dodge, IA 1 of 5Greater Southside Health and RehabilitationDes Moines, IA 1 of 5Hearthstone Health And RehabilitationSparks, NV 1 of 5Heritage Gardens Rehabilitation and HealthcareCarrollton, TX 1 of 5Hillcrest Health Care CenterHawarden, IA 1 of 5Lake Village Nursing And Rehabilitation CenterLewisville, TX 1 of 5Lakeside Rehabilitation and Care CenterCoeur d'Alene, ID 1 of 5Legend Oaks Healthcare And Rehabilitation - NorthAustin, TX 1 of 5Legend Oaks Healthcare And Rehabilitation - WaxahaWaxahachie, TX 1 of 5Legend Oaks Healthcare and Rehabilitation - Fort WKeller, TX 1 of 5Madera Post Acute CenterEl Monte, CA 1 of 5Medallion Post Acute RehabilitationColorado Springs, CO 1 of 5Mesquite Post Acute CareLubbock, TX 1 of 5Millbrook Healthcare and Rehabilitation CenterLancaster, TX 1 of 5Misty Willow Healthcare and Rehabilitation CenterHouston, TX 1 of 5New Orange HillsOrange, CA 1 of 5Northeast Rehabilitation and Healthcare CenterSan Antonio, TX 1 of 5Northgate PlazaIrving, TX 1 of 5Oak View Health And RehabilitationConway, SC 1 of 5Oakwood Care And RehabilitationLakewood, CO 1 of 5Omaha Nursing and Rehabilitation CenterOmaha, NE 1 of 5Onion Creek Nursing and Rehabilitation CenterAustin, TX 1 of 5Park Manor Bee CaveBee Cave, TX 1 of 5Pelican Pointe Health And Rehabilitation CenterWindsor, CO 1 of 5Premier Care Center For Palm SpringsPalm Springs, CA 1 of 5Provo Rehabilitation and NursingProvo, UT 1 of 5Rock Canyon Respiratory And Rehabilitation CenterPueblo, CO 1 of 5Rosewood Rehabilitation CenterReno, NV 1 of 5San Marcos Rehabilitation and Healthcare CenterSan Marcos, TX 1 of 5Sonterra Health CenterSan Antonio, TX 1 of 5SouthlandNorwalk, CA 1 of 5Southland Rehabilitation And Healthcare CenterLufkin, TX 1 of 5Spencer Post Acute Rehabilitation CenterSpencer, IA

Showing 40 of 341; lowest-rated first.

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

Who owns this facility

Owner / managerTypeRoleSince
HORN, DAVIDIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2025
JAMIL, FAHADIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 04/01/2025
BURNAM, SOONIndividualCORPORATE OFFICERsince 09/12/2024
FARNSWORTH, STEPHENIndividualCORPORATE OFFICERsince 09/12/2024
ROSS, STEVEIndividualCORPORATE OFFICERsince 09/12/2024
SATO, AMIIndividualCORPORATE OFFICERsince 09/12/2024

CMS files one row per role, so the 9 rows in the source record cover these 6 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.

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.

$28.1M
Net patient revenuemost recent cost report
-13.1%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 26%Medicare 10%Other / private 64%

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

$469per resident / day
operating cost
$14,272per month
≈ monthly operating cost
$415per 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 385018. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-05, 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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