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Avamere Rehabilitation Of Newport

835 SW 11th Street, Newport, OR 97365 · For profit - Limited Liability company · 52 certified beds · (541) 265-5356 Medicare & Medicaid certified

Call the home — (541) 265-5356 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citations — no harm found (F0740, F0758)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (30% vs 45% nationally) — better care continuity
Worth asking about
  • 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
  • its payroll-based staffing score sits well above its independent inspection score

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 3 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 4 of 5

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

Location & what’s nearby

Hospital
1/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
930 SW Abbey St · (541) 574-4795 · Call to confirm hours
Pharmacy
Walgreens0.7 mi
27 S Coast Hwy · (541) 574-4405 · Call to confirm hours
Grocery
312 SW Coast Hwy · (541) 574-6740 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
903 SW Alder St · (541) 265-5232

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 held steady at 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 increased4.5%14.9%15.4%better
Long-stay residents who lose too much weight4.5%4.7%5.4%better
Long-stay residents with a catheter left in their bladder0.6%1.4%0.9%better
Long-stay residents with a urinary tract infection2.6%2.0%2.0%worse
Long-stay residents with depressive symptoms0.0%4.9%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.6%2.4%3.3%better
Long-stay residents whose ability to walk worsened27.5%20.6%16.1%worse
Long-stay residents on antianxiety or hypnotic medication8.9%12.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%95.2%95.3%typical
Long-stay residents with pressure ulcers2.5%5.8%4.7%better
Long-stay residents with worsening bladder/bowel control13.6%21.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table9.4%13.9%17.1%better
Short-stay residents who newly got an antipsychotic medication1.9%1.4%1.4%worse
Short-stay residents given the seasonal flu vaccine94.1%81.2%79.4%better
Short-stay residents rehospitalized after admission16.7%21.4%22.6%better
Short-stay residents with an outpatient ER visit24.0%16.1%12.0%worse

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

§ 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 167 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
10.0%U.S. median 10.7%
Went back to hospital
58.8%U.S. median 56.6%
Met the expected recovery
0.24U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Met the expected recovery: 58.8% 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 80 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 0.24 therapist hours per resident per day in 2026Q1 — more than 31% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 10% 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 60.4–73.851.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.0%CMS range 7.5–13.310.7%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 discharge58.8%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 discharge56.2%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 discharge56.2%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified99.0%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 discharge95.8%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 stay1.0%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 worsened2.1%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.5%CMS range 3.5–11.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.801.02Oct 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

0.70
RN hours/ resident / day
0.41
LPN hours/ resident / day
3.34
Aide hours/ resident / day
4.46
Total nurse hours/ resident / day
0.36
RN hoursweekends
29.8%
Total nursing turnover
0.0%
RN turnover

How full it usually is: this home is certified for 52 beds and averages 39.7 residents a day — about 76% occupied, or roughly 12 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.46 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.70 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.34 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 4.08 hrs/resident/day on weekends vs 4.61 on weekdays — 11% thinner on weekends. RN hours go from 0.84 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 30% is below 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

9
deficiencies at the latest standard inspection (2025-08-08)
7
at the previous standard inspection (2024-04-04)

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 10 most serious are shown; the remaining 12 are one tap away and print in full.

  • Potential for harm · F2025-08-08 · tag F0802 — failed to prepare enough nourishing food — widespread
    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
    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 adequate staffing for meal service for 1 of 1 facility kitchen. This placed residents at risk for nutritional complications and adverse effects related to diabetic management. Findings include: A 1/30/25 Meal Time, Ticket Separation, and Dining Room memo directed CNAs and Dietary staff to communicate promptly when food or nursing staff assigned to assist with meals were delayed. The scheduled lunch start time was 11:30 AM.On 8/4/25 at 12:03 PM, Staff 8 (LPN) stated lunch was scheduled to be served at 11:30 AM in the main dining room and at 12:00 PM in other dining areas.On 8/4/25 at 12:38 PM the meal cart arrived at the North Hall Dining Room (dining room where residents received meal assistance).On 8/4/25 at 12:44 PM (74 minutes after the scheduled start of lunch service), the final hall meal cart arrived.On 8/7/25 at 10:41 AM, Staff 4 (Dietary Manager) acknowledged the kitchen was very late with meal service on 8/4/25. Staff 4 confirmed meals were routinely delayed one to two times…

    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 · Fcited before2025-08-08 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview it was determined the facility failed to maintain a sanitary kitchen environment and ensure adequate plumbing for the ice machine for 1 of 1 facility kitchen. This placed residents at risk for cross-contamination and food borne illnesses. Findings include:On 8/7/25 at 9:55 AM the following areas were observed in the kitchen:-A white painted cabinet door under the sink in the food preparation area had exposed wood and black marks around the door edge. When the cabinet door was rubbed, paint was easily removed. -The baseboard under a counter was detached from the cabinet. Black debris between the baseboard and the cabinet was visible and not accessible for cleaning. -The ice machine was directly plumbed from the outside with no one inch air gap. Under the ice machine was a metal plate attached to the floor. A one-inch-wide rim of black debris was observed around the metal plate on the floor.On 8/7/25 at 10:41 AM and 10:58 AM, Staff 4 (Dietary Manager) acknowledged there were a lot of uncleanable surfaces in the kitchen, the ice machine was not…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-08-08 · tag F0847 — widespread
    Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to ensure residents were fully informed and understood the binding arbitration agreement for 1 of 1 facility reviewed for binding arbitration agreements. This placed residents at risk of being uninformed of their legal rights. Findings include:The facility's undated Patient and Facility Arbitration Agreement stated, the parties understand and agree that by entering this arbitration agreement they are giving up and waiving their constitutional right to have any claim decided in a court of law before a judge and jury. On 8/4/25 at 10:19 AM, Staff 16 (DNS) stated all residents had signed the Patient and Facility Arbitration Agreement. On 8/7/25 at 3:31 PM, Staff 1 (Administrator) stated the facility offered a Patient and Facility Arbitration Agreement to residents upon admission. Staff 1 stated Staff 14 (Medical Records Director) was responsible for the process of explaining the agreement to residents upon admission. On 8/7/25 at 3:39 PM, Staff 14 stated she was responsible to provide residents with information…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-08 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    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 resident preferences were communicated for 1 of 1 sampled resident (#31) reviewed for choices. This placed residents at risk for lack of honored preferences. Findings include:Resident 31 was admitted to the facility in 5/2023 with diagnoses including stroke and aphasia (a disorder that impairs the ability to communicate).The 5/26/25 Annual MDS revealed Resident 31 had a BIMS assessment score of 13 (cognitively intact), was occasionally understood, and placed high importance on her/his bathing and bedtime preferences.A 5/29/25 revised care plan indicated Resident 31 required assistance from one staff member for bathing. No documented preferences regarding the resident's bathing or bedtime routine were identified.A 6/24/25 Social Services Quarterly Review indicated Resident 31 was cooperative with staff, exhibited no behavioral concerns, and the review was completed by Staff 16 (DNS).On 8/4/25 at 11:03 AM, Resident 31 communicated she/he preferred to sleep until 8:30 AM and was frequently awakened…

    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 · D2025-08-08 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    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 notify the physician after holding blood pressure medications based on decreased blood pressure for 1 of 5 sampled residents (#6) reviewed for unnecessary medications. This placed residents at risk for adverse side effects to medications. Findings include:Resident 6 was admitted to the facility in 3/2025 with diagnoses including a cerebral infarction (stroke) and hypertension (high blood pressure).A review of physician orders revealed a 5/25/25 order for Metoprolol Tartrate (a medication to treat high blood pressure) 100 mg two times a day, notify MD for further instructions and hold if blood pressure is less than 100/55.A review of Resident 6's 7/2025 MAR revealed Metoprolol was held: 7/4/25 AM dose held due to a blood pressure of 98/48 7/6/25 AM dose held, no blood pressure charted in [DATE]/14/25 AM dose held due to a blood pressure of 84/47 7/15/25 AM dose held due to a blood pressure of 98/52 7/25/25 AM dose held due to a blood…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-08 · 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

    Based on observations, interviews, and record reviews it was determined the facility failed to provide nail care to dependent residents for 1 of 2 sampled dependent residents (#6) reviewed for ADLs. This placed residents at risk for lack of dignity. Findings include: Resident 6 was admitted to the facility in 3/2025 with diagnoses including a cerebral infarction (stroke) and hemiplegia (paralysis) of the left side of the body.On 8/4/25 at 10:59 AM, Resident 6 stated her/his fingernails needed to be trimmed. Resident 6's fingernails were observed to be long, jagged, and dirty and her/his big toenails were observed to be long and jagged.On 8/7/25 at 11:13 AM, Staff 19 (CNA) stated residents received nail care on shower days. Staff 19 stated she completed nailcare for Resident 6 two weeks ago after a shower.On 8/7/25 at 2:40 PM Resident 6's fingernails and toenails were observed with Staff 3 (LPN Resident Care Manager). Resident 6's fingernails were observed to be long, jagged, and dirty and her/his big toenails were observed to long and jagged. Staff 3 stated the CNA staff 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-08 · 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 monitor for changes in skin for 1 of 1 sampled resident (31) reviewed for choices. This placed residents at risk for delayed treatment and unmet needs. Findings include: A 3/31/25 revised facility Wound Management Guideline revealed when a resident was identified to have a new skin alteration, the nurse was to obtain treatment orders, monitor the skin alteration, and document progress on the TAR.Resident 31 was admitted to the facility in 5/2023 with diagnoses including stroke and aphasia (a disorder that impairs the ability to communicate).The 5/26/25 Annual MDS indicated Resident 31 had a BIMS assessment score of 13 (cognitively intact), had no skin issues, and was sometimes difficult to understand.A 5/29/25 revised care plan revealed Resident 31 was at risk for skin impairment. Staff were to report changes regarding the resident's skin and identify potential causes.A review of the 6/2025 TAR revealed no new skin issues for Resident 31 during weekly skin audits.A 6/23/25 Late Entry Note…

    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 before2025-08-08 · tag F0740 — failed to provide behavioral / mental-health care — isolated
    Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
    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 complete a baseline care plan and provide ongoing behavioral health needs for 1 of 3 sampled residents (#46) reviewed for mood and behavior. This placed residents at risk for unmet behavioral health needs and decrease in their quality of life. Findings include: Resident 46 was admitted to the facility on [DATE] with diagnoses including depression.An 8/2/25 Progress Note revealed Resident 46 had suicidal ideations and was sent to the hospital for evaluation.An 8/3/25 Progress note revealed Resident 46 returned to the facility at approximately 2:00 AM and it was determined she/he was not at risk for imminent harm to her/himself or others.An 8/2/25 After Visit Summary indicated Resident 46 was not at risk for imminent harm to her/himself or others and Resident 46 declined completing a safety plan but agreed to complete a follow up call with Mental Health on 8/3/25.On 8/6/25 at 10:34 AM, Resident 46 stated she/he was not…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-08 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to obtain fasting serum blood sugars as ordered for 1 of 5 sampled residents (#5) reviewed for medications. This placed residents at risk for uncontrolled blood sugars. Findings include: Resident 5 was admitted to the facility in 3/2025 with diagnoses including diabetes and diabetic neuropathy (nerve pain).The 3/25/25 hospital Orders at Discharge indicated Resident 5 was to receive daily insulin (medication used to manage blood sugar levels) injections and have Fasting Serum Blood Sugars (FSBS) monitored (a method used to measure blood glucose levels after a period without food).A 6/2/25 revised care plan indicated Resident 5's diabetic medication was to be monitored for side effects and effectiveness, and FSBS were to be completed as ordered.The 7/2025 and 8/2025 Diabetic Administration Records revealed no documented FSBS results for Resident 5.On 8/4/25 at 11:19 AM, Resident 5 stated she/he was a diabetic, received insulin, and expressed concern her/his FSBS were rarely monitored.On 8/6/25 at 12:30 PM,…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-04-04 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, interview, and record review it was determined the facility failed to ensure hair and beard restraints were worn during meal preparation for 1 of 1 sampled kitchen reviewed for sanitary food practices. This placed residents at risk for contaminated food. Findings include: A review of the facility's policy Food Handling, revised 1/2018, revealed food and nutrition services staff were expected to wear hair restraints and beard nets. On 4/3/24 at 11:17 AM Staff 13 (Dietary Manager), Staff 14 (Cook) and Staff 15 (Cook) were observed preparing food in the kitchen without hair and beard restraints. Staff 13 indicated staff were told they were not required to wear hair restraints unless their hair was long, and were also told they were not required to wear beard restraints. On 4/3/24 at 11:47 AM Staff 13 acknowledged staff were to wear beard and hair restraints while working in the kitchen.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · F2024-04-04 · tag F0887 — widespread
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview it was determined the facility failed to ensure a system was in place to offer COVID-19 vaccines to staff for 1 of 1 staff (#3 [CNA]) reviewed for immunizations. This placed staff and residents at risk for infections. Findings include: On 4/3/24 At 9:09 AM a request was made to Staff 6 (Resident Care Manager) to provide documentation Staff 3 was offered a COVID-19 vaccine, including education related to the vaccine. Staff 6 stated in 8/2023 she stopped offering staff the COVID-19 vaccine.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-04 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to ensure residents were offered a pneumonia vaccine for 4 of 5 sampled residents (#s 1, 9, 11, and 13) reviewed for immunizations. This placed residents at risk for infections. Findings include: 1. Resident 1 admitted to the facility in 2023 with a diagnosis of heart disease. Resident 1's clinical record revealed she/he received a pneumonia vaccine in 2015 and was eligible for another pneumonia vaccine, but there was no indication she/he was offered another vaccine. On 4/3/24 at 9:19 AM Staff 6 (Resident Care Manager) acknowledged Resident 1 was eligible for, but was not offered another pneumonia vaccine. 2. Resident 9 admitted to the facility 2017 with a diagnosis of lung disease. Resident 9's clinical record revealed she/he received the pneumonia vaccine in 2016, was eligible for another dose, but there was no indication she/he was offered another dose. On 4/3/24 at 9:19 AM Staff 6 (Resident Care Manager) acknowledged Resident 9 was eligible for, but was not offered another pneumonia vaccine. 3. Resident…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-04 · 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

    Based on observation, interview, and record review it was determined the facility failed to ensure a resident was shaved for 1 of 1 sampled resident (#4) reviewed for ADLs. This placed residents at risk for lack of hygiene. Findings include: Resident 4 was admitted to the facility in 2023 with a diagnosis of a stroke. A 3/4/24 annual MDS revealed Resident 4 was cognitively intact. On 4/1/24 at 1:01 PM Resident 4 was observed to have facial hair. Resident 4 stated she/he preferred no facial hair and needed staff assistance on shower days to shave. Staff 4 stated she/he was scheduled to have a shower on 4/2/24. On 4/2/24 at 10:08 AM Resident 4 was observed to not be shaved. Resident 4 stated she/he was assisted to shower but was not assisted to shave. On 4/3/24 at 7:33 AM Staff 4 (CNA) stated on 4/2/24 she worked with Resident 4 during the day, but another CNA provided the resident her/his shower. Staff 4 stated the resident should have been shaved and was not. The resident's next shower day was not scheduled for two more days. Staff 4 stated the resident's facial hair was too long.…

    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 · D2024-04-04 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing 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 assist with a hearing aid device for 1 of 1 sampled resident (#30) reviewed for hearing. This placed residents at risk for social isolation and decreased quality of life. Findings include: Resident 30 admitted to the facility in 2023 with diagnosis including hearing loss. A review of Resident 30's revised care plan dated 12/21/23 revealed the resident wore two hearing aides. On 4/1/24 at 11:28 AM and 4/3/24 at 9:24 AM Resident 30 was observed to have some difficulty hearing staff and her/his roommate. The resident was observed wearing one hearing aid. When interviewed on 4/3/24 at 9:32 AM Resident 30 stated she/he had only one hearing aid because the other one was broken. Resident 30 stated she/he told staff the hearing aid was broken for a long time but no appointment was made to get the hearing aid fixed. On 4/3/24 at 4:37 PM Staff 8 (LPN), Staff 10 (CNA) and Staff 12 (CNA) stated Resident 30 wore two hearing aids. Staff verified the resident was wearing one hearing aid. On 4/5/24 10:19 AM…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-04 · 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 apply a brace for 1 of 2 sampled residents (#24) reviewed for ROM. This placed residents at risk for worsening contractures. Findings include: Resident 24 admitted to the facility in 2022 with a diagnosis of a genetic muscular disease. A 7/21/23 MDS revealed Resident 24 had cognitive impairment, limited ROM and was on a RA program. A care plan initiated 7/2022 revealed Resident 24 had a contracture of the left hand and staff were to apply a brace in the morning and remove the brace at night. On 4/1/24 at 2:22 PM, 4/2/24 at 8:17 AM and 4/3/24 at 10:29 AM Resident 24 was observed without a brace to the left hand. On 4/2/24 at 11:58 AM Staff 4 (CNA) stated the CNA staff were to apply a brace to Resident 24's left hand. Staff 4 stated she worked on 3/30/24. The washable part of the resident's brace was dirty, was taken to the facility laundry to be washed, and it was not yet returned. Staff 4 stated the piece which was washed was made from Velcro, it often stuck to other pieces of clothing, and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review it was determined the facility failed to provide care and services as care planned for 1 of 1 sampled resident (#25) reviewed for positioning. This placed residents at risk for falls. Findings include: Resident 25 admitted to the facility in 2022 with diagnosis including stroke. A 12/12/22 care plan indicated Resident 25 was at risk for falls related to stroke, incontinence, gait/balance problems, and left-sided paralysis. Resident 25 was not to be left unattended in her/his room in her/his wheelchair. On 4/3/24 at 1:42 PM and 3:12 PM, and on 4/4/24 at 8:46 AM, Resident 25 was observed in her/his room in her/his wheelchair unattended. On 4/3/24 at 10:37 AM Staff 9 (CNA), Staff 10 (CNA) and Staff 12 (CNA) stated they were not aware Resident 25 was not to be left unattended in her/his room in her/his wheelchair. On 4/4/24 at 10:32 AM Staff 6 (Resident Care Manager) stated the resident was self-transferring and was a fall risk. Staff 6 stated she saw Resident 25 recently sitting in her/his room in her/his wheelchair unattended but…

    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 · F2023-01-13 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 1. Based on observation, interview and record review it was determined the facility failed to ensure proper infection control practices were followed related to disinfecting shared medical equipment between residents, appropriate PPE use for residents on transmission-based precautions and provision of education to staff on aerosol generating procedure (AGP) precautions for 1 of 3 halls and 1 of 2 sampled residents (#230) reviewed for infection control and pressure ulcers. This placed residents at risk for cross-contamination and infections. Findings include: a. The facility's 9/28/22 policy, COVID-19 Management Overview Policy for Infection Control revealed the following: - Shared medical equipment should be cleaned and disinfected between residents. On 1/9/23 at 9:54 AM Staff 16 (CNA/CMA) was observed taking vital signs for two residents without cleaning the equipment between each resident. Staff 16 acknowledged she did not clean the equipment between each resident. On 1/12/23 at 9:30 AM Staff 11 (MDS/IP)…

    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 · E2023-01-13 · tag F0582 — pattern
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review it was determined the facility failed to ensure the correct QIO (Quality Improvement Organization) and contact information was identified on the Notice of Medicare Non-Coverage (NOMNC) letter for 3 of 3 sampled residents (#s 284, 285 and 286) reviewed for resident rights. This placed residents at risk for not being fully informed for whom to contact to appeal notices of non-coverage. Findings include: A review of three resident NOMNCs with information on the dates skilled services would end revealed the notices did not have the correct QIO and contact information should the residents decide to appeal the determination. On 1/11/23 at 12:22 PM Staff 4 (Social Services Coordinator) was asked about NOMNCs provided to residents and stated the form was provided by the facility's corporate office. Staff 4 stated he was not aware the QIO and contact information were not correct. On 1/13/23 at 10:49 AM NOMNCs were discussed with Staff 2 (DNS) and she stated she did not know who the current QIO was and agreed the form was old.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-13 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Based on interview and record review it was determined the facility failed to ensure care conferences were held and residents/resident representatives were involved with the care planning process for 2 of 2 (#20 and 24) sampled residents reviewed for care planning. This placed residents and resident representatives at risk for lack of involvement in care planning. Findings include: a. Resident 24 was admitted to the facility in 2022 with diagnoses including stroke. On 1/9/23 at 12:55 PM Witness 1 (resident representative) was asked about participation in care planning. Witness 1 stated she/he did not participate in a care conference or care planning. The resident's record indicated a comprehensive assessment dated [DATE] was completed. There was no evidence a care conference occurred following the completion of the 12/15/22 assessment. On 1/12/23 at 2:13 PM Staff 11 (MDS Coordinator) stated the RNCM was usually the person who participated in care conferences but depending on availability Staff 11 may…

    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 · D2023-01-13 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review it was determined the facility failed to ensure pressure ulcers were accurately assessed and routinely monitored for healing for 1 of 3 sampled residents (#5) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include: The NPIAP (National Pressure Injury Advisory Panel) Staging Guidelines describes a Stage 2 Pressure Ulcer as partial-thickness skin loss with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. The facility's updated Skin and Wound Management Policy and Procedure revealed the following: - The RCM (RNCM) or designee will evaluate any new impaired skin integrity and document findings in the clinical record. - Actual skin areas will have weekly documentation that includes measurements and how the wound is progressing towards healing (improvement, worse and unchanged). Resident 5 admitted to the facility 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 · Dcited before2023-01-13 · tag F0740 — failed to provide behavioral / mental-health care — isolated
    Ensure each resident must receive and the facility must provide necessary behavioral health care and 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 behavioral healthcare services for 1 of 2 sampled residents (#25) reviewed for Behavioral and Emotional concerns. This placed residents at risk for increased mental health concerns. Findings include: Resident 25 was admitted to the facility in 12/2022 with diagnoses which included stroke, chronic pain and depression. Resident 25's care plan dated 12/15/22 indicated the resident was at risk for: mood, behavior and psychosocial issues related to a loss of self-control and stroke. The goal was for the resident to have no decline in mood or behavior through the next review date. Staff were to arrange 1:1 interaction with the Social Service Coordinator (SSC) for adjustment to placement in the facility weekly and/or as needed and notify the SSC of any decline in mood or behavior. No documentation for 1:1 interactions with the SSC were documented in the resident's medical record. A 12/19/22 at 6:04 PM Nursing Care Note indicated Resident 25 stated she/he wanted to die due to uncontrollable…

    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 · D2023-01-13 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to ensure there was an appropriate indication for use of a psychotropic medication for 1 of 5 sampled residents (#6) reviewed for unnecessary medications. This placed residents at risk for unnecessary medications. Findings include: Resident 6 was admitted to the facility in 11/2022 with diagnoses including dementia with behavioral disturbance, sepsis and pneumonia. A physician order dated 11/17/22 indicated the resident was prescribed a memory drug for dementia without behavioral disturbance. An admission 5-day MDS dated [DATE] contained a Psychotropic Drug Use CAA which indicated the resident was on Seroquel (an antipsychotic medication) for dementia with behavioral disturbance. The plan was to monitor for additional adverse symptoms and discuss alternative medications or measures to treat the behaviors without the use of the medication. No documentation was found in the record to indicate alternative medications or measures 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.

    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 AVAMERE — 27 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 53.0+1.0 vs chain
Health inspection 3 of 52.6+0.4 vs chain
Staffing 5 of 54.0+1.0 vs chain
Quality measures 4 of 53.8+0.2 vs chain
The other 26 homes this chain runs (chain average 3.0★, per CMS)
1 of 5Avamere Rehabilitation Of EugeneEugene, OR 1 of 5Avamere Rehabilitation Of LebanonLebanon, OR 2 of 5Avamere At Pacific RidgeTacoma, WA 2 of 5Avamere Health Services Of Rogue ValleyMedford, OR 2 of 5Avamere Olympic Rehabilitation Of SequimSequim, WA 2 of 5Avamere Rehabilitation At Park WestSeattle, WA 2 of 5Avamere Rehabilitation Of Coos BayCoos Bay, OR 2 of 5Avamere Rehabilitation Of IssaquahIssaquah, WA 2 of 5Avamere Rehabilitation Of Oregon CityOregon City, OR 2 of 5Avamere Rehabilitation Of ShorelineSeattle, WA 2 of 5Avamere Rehabilitation of BurienBurien, WA 2 of 5Avamere Riverpark Of EugeneEugene, OR 2 of 5Avamere Transitional Care At SunnysideSalem, OR 3 of 5Avamere Rehabilitation Of HillsboroHillsboro, OR 4 of 5Avamere Court At KeizerKeizer, OR 4 of 5Avamere Crestview Of PortlandPortland, OR 4 of 5Avamere Rehabilitation At RidgemontPort Orchard, WA 4 of 5Avamere Rehabilitation Of ClackamasGladstone, OR 4 of 5Avamere Rehabilitation Of Junction CityJunction City, OR 4 of 5Avamere Rehabilitation Of King CityTigard, OR 4 of 5Avamere Transitional Care Of Puget SoundTacoma, WA 4 of 5Richmond Beach RehabShoreline, WA 4 of 5The PEARL AT KRUSE WAYLake Oswego, OR 5 of 5Avamere At Three FountainsMedford, OR 5 of 5Avamere Rehabilitation Of Cascade ParkVancouver, WA 5 of 5Queen Anne HealthcareSeattle, WA

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
ARISO LLCOrganizationDIRECT OWNERSHIP INTERESTsince 01/06/2006
ARI OPERATIONS, LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 01/06/2006
AVAMERE GROUP LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 01/06/2006
KARL RICKARD MILLER JR REVOCABLE TRUSTOrganizationINDIRECT OWNERSHIP INTERESTsince 07/11/2011
MILLER, KARLIndividualINDIRECT OWNERSHIP INTERESTsince 08/01/1996
MIDCAP FINCO LLCOrganization5% OR GREATER SECURITY INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 01/22/2010
CAVALLO, GLENIndividualMANAGING CONTROL - GOVERNING BODYsince 06/01/2025
FEAKIN, CODYIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
FUNDERBERG, MICHELLEIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 01/01/2025
GARCIA, ROBERTOIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2026
INSKEEP, TODDIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 01/21/2022
KOFSTAD, MARYIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/13/2024
REID, MISTYIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/02/2025
STAPLES, CAROLYNIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 10/01/2025
STRUNK, COLBYIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 06/01/2025
VANDERZANDEN, CARRIEIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 01/02/2025
AVAMERE HEALTH SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2005
AVAMERE SKILLED ADVISORS LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2005
BARBER, DANIELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/02/2026
DEIS, MICHELLEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/02/2021
HOSKINS, TONIAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 07/19/2024
LARSON, DAVIDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2020
PRESLEY, YOLANDAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/06/2025
TODD, LORELEIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/16/2024
RANDE HOLDINGS, LLCOrganizationADP OF THE SNFsince 06/01/2024
SABRA HEALTH CARE REIT INCOrganizationADP OF THE SNFsince 08/17/2017
SABRA HEALTH CARE, LLCOrganizationADP OF THE SNFsince 08/17/2017
SNAPMEDTECH,INC.OrganizationADP OF THE SNFsince 09/08/2025
BECERRA, SHANNONIndividualADP OF THE SNFsince 02/01/2025
FOWLER, KATHERINEIndividualADP OF THE SNFsince 02/08/2025
GAMES, KIMIndividualADP OF THE SNFsince 08/15/2024
GORRINGE, SHAUNAIndividualADP OF THE SNFsince 11/04/2016

CMS files one row per role, so the 53 rows in the source record cover these 32 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.

11 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.

$7.0M
Net patient revenuemost recent cost report
-2.2%
Operating marginrevenue minus expenses
$883K
Related-party expense12% of expenses
Who pays — share of resident-days
Medicaid 48%Medicare 21%Other / private 31%

This home reported $883K paid to related parties — landlords or management companies under common ownership — equal to about 12% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

$562per resident / day
operating cost
$17,087per month
≈ monthly operating cost
$550per 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 385162. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-08, 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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