Glisan Post Acute
9750 NE Glisan Street, Portland, OR 97220 · For profit - Limited Liability company · 100 certified beds · (503) 256-3920 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has 1 actual-harm citation
- inspectors recorded 2 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (34) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 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 fell from 3 to 2 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 10.9% | 14.9% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.0% | 4.7% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.4% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.4% | 2.0% | 2.0% | better |
| Long-stay residents with depressive symptoms | 6.8% | 4.9% | 6.5% | typical |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.2% | 2.4% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 21.3% | 20.6% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 13.4% | 12.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.3% | 5.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 15.9% | 21.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.7% | 13.9% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.3% | 1.4% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 86.8% | 81.2% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 13.2% | 21.4% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 28.0% | 16.1% | 12.0% | worse |
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
46.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 31 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 50.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 22 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 0.10 therapist hours per resident per day in 2026Q1 — more than 6% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 22% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 46.6%CMS range 31.9–68.0 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.5%CMS range 6.7–16.2 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 50.0% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 40.9% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 50.0% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 90.3% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | not 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 discharge | 76.2% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.20 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 100 beds and averages 78.0 residents a day — about 78% occupied, or roughly 22 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 4.74 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.59 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.48 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 4.19 hrs/resident/day on weekends vs 4.96 on weekdays — 16% thinner on weekends. RN hours go from 0.59 to 0.59 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 48% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
34 citations, most serious first. The 13 most serious are shown; the remaining 21 are one tap away and print in full.
- Actual harm · Gcited before2024-07-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review it was determined the facility failed to ensure cognitively impaired residents did not have access to excessively hot liquids for 1 of 3 sampled residents (#2) reviewed accidents and hazards. This failure resulted in Resident 1 sustaining a second-degree burn (partial thickness involving the first two layers of skin) to her/his thigh. Findings include: Resident 2 was admitted to the facility in 9/2022 with diagnoses including diabetes. A 11/13/23 progress note indicated Staff 9 (Agency CNA) notified Staff 2 (LPN) that Resident 2 spilled hot coffee on her/his lap. A 11/13/23 facility investigation revealed nursing staff took the coffee cart out of the kitchen prior to the coffee cooling to a safe temperature. Resident 2 was provided with coffee that was too hot (above 155 degrees). The resident was found by Staff 9 after she/he spilled the coffee in her/his lap. A 11/23/23 progress note indicated Resident 2 was assessed to have a second degree burn described as a large area of reddened skin noted to the right lateral thigh with several ruptured…
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.
- Actual harm · Gcited before2024-03-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review it was determined the facility failed to follow the resident's plan of care for 1 of 1 sampled resident (#1) reviewed for falls. As a result, Resident 1 fell and suffered a subarachnoid hemorrhage (brain bleed), and placed all residents at risk for significant injury. Findings include: Resident 1 admitted to the facility in 11/2011 with diagnoses including heart failure and osteoporosis. The 1/7/24 Annual MDS revealed Resident 1 had moderate cognitive impairment. The 1/15/24 ADL Care Plan revealed Resident 1 required two person extensive assistance for bed mobility and two or more person assistance to transfer with the mechanical lift. The 3/19/24 Progress Notes revealed at 5:30 AM, Resident 1 fell out of bed, hit her/his head on the floor and assessed to have a bruise on her/his scalp. The floor mats were not in place at the time of the fall as they were removed in preparation for the upcoming mechanical lift transfer. At approximately 11:00 AM, the resident complained of increased neck and upper back pain, the provider was notified and 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.
- Actual harm · Gcited before2023-08-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 it was determined the facility failed to ensure fall risk interventions were followed for 1 of 1 sampled resident (#13) reviewed for accidents. This resulted in Resident 13 sustaining wrist and leg fractures which placed residents at risk for falls and injuries. Findings include: Resident 13 was admitted to the facility in 2021 with diagnoses including chronic obstructive pulmonary disease (difficulty breathing), stroke and diabetes. Resident 13's Annual MDS dated [DATE] indicated the resident was moderately impaired in cognition and needed extensive assistance with ADLs. Resident 13's Care Plan dated 6/21/23 identified the resident was at risk for falls due to gait/balance problems. Interventions on the care plan included: extensive two-person assistance for bed mobility, staff were to anticipate the resident's needs, keep the call light and personal items within reach, the resident was to wear non-skid footwear and promptly respond to all requests for assistance. A FRI…
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.
- Potential for harm · E2026-03-13 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review it was determined the facility failed to ensure medications and biologicals were secured for 1 of 4 medication carts and 1 of 3 treatment carts reviewed for safe medication storage. This placed residents at risk for unauthorized access to medications. Findings include: The facility's undated Storage of Medication Policy indicated only licensed nurses, pharmacy staff and those lawfully authorized to administer medications (such as medication aides) are allowed access to the medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access. 1. On 3/11/26 from 5:08 AM to 5:22 AM, an unlocked and unattended treatment cart was observed in the east hall across from the nurse's station. Two boxes of enoxaparin (an injectable anticoagulant [blood thinner]) for Resident 15 were observed on top of the cart. CNA staff were in the area, one resident was observed to self-propel in her/his wheelchair near the cart, and the contents of the cart were accessible. On…
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.
- Potential for harm · Ecited before2026-03-13 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review it was determined the facility failed to properly store food and failed to maintain sanitary conditions for 1 of 1 unit refrigerators and 1 of 1 unit freezers. This placed residents at risk for food borne illness and contaminated food. Findings include:The facility's 11/2022 Food Receiving and Storage Policy indicated:-All foods stored in the refrigerator or freezer are covered, labeled and dated; and;-Foods in the walk-ins are stored off the floor. On 3/9/26 at 9:03 AM, observation of the unit refrigerator and the unit freezer revealed the following items:-Two unlabeled, undated plastic bags of hot dogs;-One unlabeled, undated large container of sliced pepperonis;-One unlabeled, undated small container of lemon wedges;-One unlabeled, undated large container of shredded cheese;-One unlabeled plastic container of pulled pork;-One unlabeled medium container of corn dated 3/2;-One unlabeled medium container of chicken fried steak dated 2/17;-One unlabeled medium container of spaghetti sauce dated 12/3;-One box of opened ice cream bars…
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.
- Potential for harm · Ecited before2026-03-13 · tag F0880 — failed to prevent and control infections — patternProvide 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 Based on observation, interview and record review it was determined the facility failed to ensure appropriate use and disposal of personal protective equipment in accordance with CDC guidelines and failed to ensure the separation of soiled and clean linens for 1 of 1 facility. These failures placed residents at risk for infections and cross contamination. Finding include: The CDC's 2/11/25 Eye Protection for Infection Control website, https://www.cdc.gov/niosh/ppe/eye-safety/infection-control.html, specified to remove eye protection, such as face shields, by only handling the parts that secure it to the head (like plastic temples, elastic bands, or ties) and to avoid touching the front of face shields, as those surfaces are most likely contaminated by sprays or droplets. Non-disposable eye protection should be placed in a designated container for cleaning and disinfection. The facility's Droplet/Contact Precautions sign dated 5/2020 included the following: - Wear eye protection (face shield or goggles).- Remove…
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.
- Potential for harm · D2026-03-13 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review it was determined the facility failed to ensure residents were assessed to self-administer medications for 3 of 3 sampled residents (#s 10, 13 and 60) reviewed for self-administration. This placed residents at risk for unsafe medication administration. Findings include:The facility's Self Administration of Medication dated 8/2024 included the following:- No medications are stored at bedside nor self-administered until evaluation complete.- A physician order is obtained indicating the specific medications that resident is able to self-administer.- If the resident chooses to have the medications at the bedside, they are contained in a locked cupboard or drawer.- Medications are indicated on the MAR as self-administered. - The resident is reevaluated for continued ability to self-administer their medications annually and with significant change in condition.1. Resident 60 was admitted to the facility 7/2025 with diagnosis of metabolic encephalopathy (a syndrome of global brain dysfunction caused by underlying systemic illnesses). 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.
- Potential for harm · Dcited before2026-03-13 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review it was determined the facility failed to ensure a comfortable and homelike environment for 1 of 1 sampled resident (#1) reviewed for environment. This placed residents at risk for lack of a homelike environment and loss of sleep. Findings include:The facility's 2/2021 Homelike Environment Policy indicated the facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting, including comfortable sound levels. Resident 1 was readmitted to the facility in 3/2023 with diagnoses including insomnia. Resident 1's 2/5/26 Quarterly MDS revealed the resident was cognitively intact. On 3/10/26 at 9:50 AM, Resident 1 was observed in her/his room in bed. Resident 1 stated the backdoor, located just outside of her/his room, was broken and the alarm attached to the door would ring and ring and ring when the door was not shut properly. Resident 1 stated the sound of the alarm was constant, and at night, it prevented her/him from sleeping. Resident 1 stated 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.
- Potential for harm · D2026-03-13 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
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 complete comprehensive assessments in the areas of cognition and mood for 1 of 1 sampled resident (#62) reviewed for respiratory care. This placed residents at risk for inaccurate assessments and unassessed needs. Findings include:Resident 62 was admitted to the facility in 2/2026 with diagnoses including acquired absence of larynx (the surgical removal of the voice box [laryngectomy]) and encounter for attention to tracheostomy (a surgically created opening [stoma] in the front of the neck leading directly into the trachea [windpipe] to create a new airway for breathing). Resident 62's 2/26/26 admission MDS revealed the resident had no speech but was able to communicate to and understand others without difficulty. The MDS further revealed the Brief Interview for Mental Status (BIMS) and Resident Mood Interview (PHQ-2 to 9) were not completed as the resident was rarely/never understood. On 3/9/26 at 11:51 AM, Resident 62 was observed in her/his room. The resident was nonverbal but able 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.
- Potential for harm · Dcited before2026-03-13 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 provide the necessary care and assistance to maintain good grooming and hygiene for 2 of 2 sampled residents (#s 3 and 72) reviewed for ADLs. This placed residents at risk for poor grooming and loss of dignity. Findings include:1 Resident 3 was admitted to the facility in 9/2025 with diagnoses including quadriplegia and Type 2 diabetes. On 3/9/26 at 11:10 AM Resident 3 was observed in her/his room. Resident 3's fingernails were long and contained a thick, skin-colored debris beneath the nails. The ADL Function CAA dated 8/14/25 indicated Resident 3 required maximum assistance with all ADLs. A Physician Order dated 9/10/25 directed a licensed nurse to check Resident 3's fingernails and toenails weekly on bath days and trim as needed. A review of the 2/2026 and 3/2026 TAR indicated a licensed nurse was to check Resident 3's fingernails and toenails weekly on bath days and trim as needed. On 3/10/26 at 2:22 PM Staff 10 (CNA) stated a licensed nurse would have to trim Resident 3's fingernails due…
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.
- Potential for harm · Dcited before2026-03-13 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review it was determined the facility failed to provide an ongoing person-centered activities program for 1 of 2 sampled residents (s 3) reviewed for activities. This placed residents at risk for a decline in psychosocial well-being and diminished quality of life. Findings include: An undated Facility Activity Programs Policy Statement indicated:-Activity programs are designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident.-The activities program is provided to support the well-being of residents and to encourage both independence and community interaction.-Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident.-The activities program is ongoing and includes facility organized group activities, independent individual activities and assisted individual activities.-Activities are scheduled 7 (seven) days a week.-Our activity programs consist of individual, small group and large group activities designed to meet the needs 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.
- Potential for harm · Dcited before2026-03-13 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review it was determined the facility failed to ensure residents were comprehensively assessed to independently perform tracheostomy care and a person-centered care plan was developed for respiratory care for 1 of 1 sampled resident (#62) reviewed for respiratory care. This placed residents at risk for respiratory distress and unmet needs. Findings include:The facility's 8/2024 Respiratory Treatment Policy and Procedure indicated residents received respiratory treatments and monitoring according to their physician orders, standards of practice and care plan. Resident 62 was admitted to the facility in 2/2026 with diagnoses including acquired absence of larynx (the surgical removal of the voice box [laryngectomy]) and encounter for attention to tracheostomy (a surgically created opening [stoma] in the front of the neck leading directly into the trachea [windpipe] to create a new airway for breathing). Resident 62's 2/20/26 Nursing admission Assessment indicated the resident was cognitively intact, nonverbal and communicated her/his needs 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.
- Potential for harm · D2026-03-13 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each resident.
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 dental services for 1 of 2 sampled residents (#16) reviewed for dental. This placed residents at risk for difficulty with eating. Findings include:Resident 16 was admitted to the facility in 10/2020 with diagnoses including malnutrition.A 12/8/25 Quarterly MDS indicated Resident 16 had a BIMS score of 15 which indicated Resident 16 was cognitively intact. A 10/27/20 Care Plan indicated staff coordinated and made arrangements for dental care services and indicated Resident 16 had her/his own teeth. A 7/22/25 Dental Treatment Summary indicated Resident 16 had all her/his teeth extracted. On 3/9/26 at 2:38 PM, Resident 16 stated she/he had all her/his teeth extracted eight months earlier, had repeatedly asked staff about getting dentures without receiving a response, and was having trouble chewing and eating.On 3/12/26 at 11:35 AM, Staff 42 (CNA) stated Resident 16 had her/his own teeth and did not require assistance to complete dental hygiene. On 3/12/26 at 12:21 PM and 1:26 PM, Staff 19 (Social…
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.
Show the remaining 21 citations
- Potential for harm · Ecited before2025-07-09 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview it was determined the facility failed to ensure kitchen equipment and food preparation areas were maintained in a clean and sanitary manner for 1 of 1 kitchen reviewed for sanitary kitchen practices. This placed residents at risk of illness and contaminated food. Finding include: The facility's Cleaning and Sanitation of Department: Food and Nutritional Services policy, dated 12/11/15, indicated the following: -The food and nutritional services manager would assure compliance of all cleaning and sanitation tasks needed in the department. Observation of the facility's kitchen on 7/8/25 between the hours of 9:30 AM and 2:30 PM, revealed the following: -A fan was blowing directly into the food preparation area with numerous spots of dust and debris clumps on the fan covering. -There was an orange/brown hard coating completely covering the inside of each oven door, and a black, hard substance covering the entire bottom of the oven and on the oven racks. -The grill had hard, burnt substances on the cooking surface, sticky grease-like splashes and food…
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.
- Potential for harm · D2025-03-20 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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 reorder a medication in a timely manner resulting in missed medications for 1 of 3 residents (# 7) reviewed for medication administration. This placed residents at risk for increased pain. Findings include: Resident 7 was admitted to the facility in 5/2022 with diagnoses including chronic pain. An 11/14/24 Physician Order included 5 mg of oxycodone scheduled to be administered three times a day to assist with pain reduction. Review of 11/14/24 through 12/15/24 Narcotic Book records for oxycodone revealed Resident 7 did not receive her/his scheduled evening dose on 12/4/24 and scheduled morning dose on 12/5/24. A 12/2/24 Pharmacy fax stated the pharmacy was unable to dispense the medication because no refill was available and new orders were required to receive Resident 7's oxycodone medication. Physician orders were placed on 12/4/24 at 9:00 PM to continue Resident 7's oxycodone at 5 mg three times a day to assist with pain reduction. On 3/19/25 at 12:14 PM Resident 7 stated two doses of her/his scheduled…
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.
- Potential for harm · Ecited before2024-11-22 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to maintain sanitary equipment to prevent the unintended presence of potentially harmful substances, label and store food appropriately or handle and prepare food in a sanitary manner for 1 of 1 ice machine, 1 of 1 mobile ice carts and 1 of 1 kitchen reviewed for dining services. This placed residents at risk of illness and contaminated food. Finding include: In the dining room on 11/18/24 at 12:25 PM Staff 21 (CNA) was observed to scoop ice from the large ice machine into the mobile ice cart chest. Staff 21 used the ice scoop located to the left of the ice machine, mounted on the wall and contained in a black container. Staff 21 was then observed to use an ice scoop, stored in a white mesh bag on the mobile ice cart, to place ice into a cup. The white mesh bag had a black substance on the bottom of the bag about the size of a playing card. On 11/18/24 at 12:28 PM Staff 21 stated they did not know if the white mesh bag 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.
- Potential for harm · Dcited before2024-11-22 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview it was determined the facility failed to ensure shower rooms were clean and in good repair for 1 of 3 shower rooms and to accommodate residents with wheelchair arm rests in proper cleanable order for 2 of 7 sampled residents (#28 and 40) reviewed for environment. This placed residents at risk for lack of a clean and homelike environment and with personal equipment in disrepair. Findings include: 1. Multiple random observations from 11/18/24 through 11/20/24 between the hours of 8:00 AM and 4:00 PM revealed the shower on the TCU (Transitional Care Unit) had a black colored substance along the entire metal floor board edging, the left front corner of the shower's flooring had several deep cracks with black substance in the cracks, the overhead fan had a layer of dirt/dust in all vents and made a loud grinding noise. On 11/20/24 at 9:03 AM Staff 14 (Housekeeping Supervisor) confirmed the TCU shower floor board edging was rusted and could not be cleaned, the left corner flooring was cracked and not cleanable and the fan was dirty. Staff 14 acknowledged…
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.
- Potential for harm · D2024-11-22 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
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 initiate a grievance process for 1 of 2 sampled residents (#169) reviewed for personal property. This placed residents at risk for unaddressed concerns. Findings include: Resident 169 admitted to the facility in 10/2024 with diagnoses of displaced intertrochanteric fracture of left femur and schizophrenia. On 11/18/24 at 12:27 PM Resident 169 stated after he/she arrived staff took her/his clothes to the laundry and did not return them. Resident 169 stated to several staff members that her/his clothing items were missing. Resident 169's 10/31/24 inventory sheet revealed Resident 169 admitted with a shirt, underpants and jeans. On 11/21/24 at 9:54 AM Staff 14 (Housekeeping Supervisor) stated if a resident reported a missing item staff looked for the item. If the item was not found, staff would assist the resident to fill out a grievance form. Staff 14 indicated she/he was not aware Resident 169 was missing clothing. On 11/21/24 at 12:34 PM Staff 22 (CNA) stated resident 169 mentioned her/his clothing 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.
- Potential for harm · D2024-11-22 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
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 appropriate treatment and services in the area of communication for 1 of 2 sampled residents (#9) reviewed for communication. This placed residents at risk for diminished quality of life and potential decline in their ability to carry out activities of daily living. Findings include: Resident 9 was admitted to the facility in 10/2019 with diagnoses including hemiparesis (partial weakness on one side of the body) and hemiplegia (complete paralysis on one side of the body) following a stroke affecting the left non-dominant side. Resident 9's 9/11/24 Annual MDS Assessment indicated the resident was moderately cognitively impaired, experienced moderate difficulty hearing, the resident's preferred language was Vietnamese and she/he wanted an interpreter to communicate with health care staff. The Communication CAA indicated staff who communicated with the resident needed to elevate their voice, face the resident 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.
- Potential for harm · Dcited before2024-11-22 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 provide adequate bathing for 1 of 3 sampled residents (#37) reviewed for ADLs. This placed residents at risk for unmet hygiene needs. Findings include: Resident 37 was admitted to the facility in 11/2023 with diagnoses including neuromuscular dysfunction of the bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems). Resident 37's 8/25/24 Quarterly MDS Assessment indicated the resident was cognitively intact and dependent upon staff assistance for showers/bathing. Resident 37's 9/23/24 ADL Care Plan revealed the resident was to receive showers on Monday and Friday evenings. Resident 37's 10/25/24 through 11/18/24 Bathing Task sheet revealed the following: -10/25/24, Friday: not applicable. -11/4/24, Monday: resident refused. No documentation was found to indicate the resident was reoffered a shower during the shift, the resident's refusal was reported to the nurse or the resident was reoffered a shower on an alternative shift. -11/8/24, Friday: not applicable.…
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.
- Potential for harm · Dcited before2024-11-22 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review it was determined the facility failed to provide an ongoing person-centered activity program for 2 of 4 sampled dependent residents (#s 9 and 36) reviewed for activities. This placed residents at risk of a decline in psychosocial well-being and diminished quality of life. Findings include: The facility's Activity Evaluation policy, dated 2/2023 and Activities Attendance policy, dated 6/2018 indicated the following: -The activity evaluation was used to develop an individualized activity care plan that allowed the resident to participate in activities of her/his choice and interest. -Each resident's activities care plan related to her/his comprehensive assessment and was reflective of the resident's individual needs. -Attendance and participation was recorded for every resident in group and individual activities on a daily basis. 1. Resident 36 was admitted to the facility in 5/2024 with diagnoses including cardiomyopathy (a disease of the heart muscle), dementia, restlessness and anxiety disorder. Resident 36's 6/11/24 Activities…
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.
- Potential for harm · D2024-11-22 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 3 sampled residents (#16) reviewed for pain. This placed residents at risk for ongoing pain or over sedation. Findings include: Resident 16 was admitted to the facility in 10/2024 with diagnoses including chronic pain and opioid dependency (a chronic brain disease that causes a person to compulsively seek out opioid pain medications). a. An 11/2/24 Physician Order indicated Resident 16 was prescribed oxycodone (an opioid medication used for pain management) 10 mg every 4 hours as needed for severe pain of 7 to 10 out of a pain scale of 10. A review of Resident 16's 11/2024 MAR revealed the resident was administered 10 mg of oxycodone outside of the physician's parameters on the following days: -11/10/24: pain was documented as 5; -11/13/24: pain was documented as 6; -11/16/24: pain was documented as 5 and -11/20/24: pain was documented as 6. On 11/22/24 at 8:19 AM Staff 2 (DNS) reviewed Resident 16's 11/2024 MAR and acknowledged on 11/10/24, 11/13/24, 11/16/24…
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.
- Potential for harm · D2024-11-22 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide 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 implement interventions to prevent pressure ulcers and skin breakdown for 1 of 1 sampled resident (#37) reviewed for skin conditions. This placed residents at risk for the development of pressure ulcers and skin breakdown. Findings include: Resident 37 was admitted to the facility in 11/2023 with diagnoses including neuromuscular dysfunction of the bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems). Resident 37's 8/25/24 Quarterly MDS Assessment revealed the resident was cognitively intact, at risk to develop pressure ulcers/injuries and to have a pressure reducing device for her/his chair. Resident 37's 11/2024 Physician Orders directed the resident to receive wound care to her/his right and left thigh rear skin tears twice daily. On 11/18/24 at 12:33 PM Resident 37 was observed in her/his room and sat on a folded towel in her/his wheelchair. Resident 37 stated she/he experienced skin irritation and breakdown on her/his bottom area and she/he did 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.
- Potential for harm · D2024-11-22 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide 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 appropriate treatment and services to prevent further decreases in range of motion for 2 of 3 sampled residents (#s 9 and 10) reviewed for position and mobility. This placed residents at risk for worsening contractures (a permanent tightening of the muscle, tendons and skin causing the joint to shorten and stiffen) and conditions. Findings include: The facility's 8/2024 Restorative Nursing Policy and Procedure revealed the following: -On-going assessment of each resident's functional status occurred no less often than quarterly with completion of the MDS. -If the Resident Care Manager or licensed staff determined the resident had the ability to improve in one or more area of communication, mobility, range of motion, ADL performance, eating or toileting, a therapy referral or restorative nursing referral was initiated. -If the resident expressed a desire to improve in one or more area of communication, mobility, range of motion, ADL performance, eating or toileting, a restorative…
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.
- Potential for harm · D2024-11-22 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to ensure residents who were trauma survivors received trauma-informed care for 1 of 2 sampled residents (#62) reviewed for mood. This placed residents at risk for re-traumatization and decreased quality of life. Findings include: The facility's 8/2024 Trauma-Informed Care Policy and Procedure revealed the following: -The facility screened newly admitted residents for indications of trauma as part of the comprehensive care plan process. -The facility developed an appropriate plan of care and interventions based upon the screening responses and observations of the resident. -The facility avoided re-traumatization that may be experienced due to repeated interviews regarding trauma history. The facility observed the resident for changes in behavior or mood that may indicate a need to modify the plan of care, quarterly. Resident 62 was admitted to the facility in 9/2024 with diagnoses including Post traumatic stress disorder…
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.
- Potential for harm · D2024-11-22 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure 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 necessary behavioral health care and services for 1 of 2 sampled residents (#62) reviewed for behavioral-emotional needs. This placed residents at risk for unmet behavioral and emotional needs and a decrease in their quality of life. Findings include: The facility's 2/2019 Behavioral Health Services and 3/2019 Behavioral Assessment, Intervention and Monitoring Policies revealed: -Residents who exhibit signs of emotional/psychosocial distress receive services and support that address their individual needs and goals for care. -As part of the comprehensive assessment, staff will evaluate, based on input from the resident, family and caregivers, review of medical record and general observations, the resident's typical or past responses to stress, fatigue, fear, anxiety frustration and other triggers and the resident's previous patterns of coping with stress, anxiety and depression. -Interventions will be individualized and part of an overall care environment that supports physical,…
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.
- Potential for harm · D2024-11-22 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
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 accommodate resident food choices for 1 of 7 sampled residents (#37) reviewed for food. This placed residents at risk for food choices not being honored. Findings include: Resident 37 was admitted to the facility in 11/2023 with diagnoses including neuromuscular dysfunction of the bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems). Resident 37's 11/22/23 Food and Nutrition admission Interview revealed the resident normally ate oatmeal for breakfast and requested a salad with meals. The Interview also indicated the resident did not like peas, green beans, pepper, raisin bread or raisins. Resident 37's 8/25/24 Quarterly MDS Assessment revealed the resident was cognitively intact and on a therapeutic diet. Resident 37's 11/11/24 Nutrition At Risk Evaluation revealed the resident received a regular texture diet with small starch portions and sodium limited to two grams. The resident was to receive a salad with lunch and dinner. On 11/18/24 at 1:31 PM 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.
- Potential for harm · Ecited before2023-08-11 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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 observations and interviews it was determined the facility failed to maintain a clean and homelike environment for 1 of 1 facility reviewed for environment. This placed residents at risk for living in an unkempt and along environment. Findings include: Observations of the facility's general environment and residents' rooms on 8/7/23 through 8/10/23 identified the following issues: -room [ROOM NUMBER] had a large dirty spot on the floor in the center of the room and the edges of the flooring and the room's corners had a build-up of dirt. The floors under the lip of the closets and cabinets had a build-up of dirt and grime and the metal base of the sliding glass door had a build-up of dirt inside the base and along the edges of the floor. -Rooms 107, 126 and 127 had corners missing in the floor boards. -The flooring in room [ROOM NUMBER] had a build-up of dirt along the edges and in the corners. There was a large spill in the center of the room and missing flooring under the window. -room [ROOM NUMBER]…
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.
- Potential for harm · E2023-08-11 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs for 1 of 1 facility reviewed for sufficient and competent staffing. This placed residents at risk for delayed and unmet care needs. Findings include: On 8/7/23 the facility had a census of 63 and provided a list of residents who: -Required one or two-person assistance with bathing: 19. -Were fully dependent for bathing: 31 -Required one or two-person assistance with dressing: 57. -Were fully dependent for dressing: 2. -Required one or two-person assistance with transfers: 32 -Were fully dependent for transfers: 17. -Required one or two-person assistance with toileting: 49. -Were fully dependent for toileting: 2. -Required one or two-person assistance with eating: 19. -Were fully dependent for eating: 1. -Were occasionally or frequently incontinent of bladder: 36. -Were occasionally or frequently incontinent of bowel: 27. -Had behavioral healthcare needs: 10. On 8/9/23 the facility provided a list of 19 residents who required a two-person mechanical…
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.
- Potential for harm · Ecited before2023-08-11 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 store food in a sanitary manner for 1 of 1 facility kitchen reviewed for sanitary food storage. This placed residents at risk for food-borne illness and contaminated food. Findings include: 1. On 8/7/23 at 9:05 AM during the initial tour of the facility's walk-in refrigerator and dry storage room the following were observed: Walk-in refrigerator: -An open and undated container of fruit salad; -An open and undated bag of cheese slices; -Two containers of butter undated and not labeled; -A container of applesauce undated and not labeled; -A plastic bag of meat dated 4/27/23; -A plastic bag of shredded cheese not labeled or dated; -An open bag of sliced roast beef not sealed, with no opened date; -A plastic bag of boiled eggs not labeled or dated; -Multiple individual containers of salad dressing not labeled or dated; -A box of russet potatoes on the floor; -A plastic bag of sliced ham not labeled or dated; -A plastic bag of sliced meatloaf not labeled or dated; and -Poured drinks on a cart with plastic lids…
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.
- Potential for harm · Dcited before2023-08-11 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review it was determined the facility failed to follow physician's orders for supplemental oxygen for 1 of 1 sampled resident (#21) reviewed for oxygen. This placed residents at risk for unmet respiratory needs. Findings include: Resident 21 was admitted to the facility in 2021 with diagnoses including acute respiratory failure. Physician Orders on 7/8/23 indicated Resident 21 required supplemental oxygen to be administered at 2 liters per minute (LPM) as needed for respiratory distress, shortness of breath, difficulty breathing or cyanosis (pale, blue, lips). On 8/7/23 at 2:28 PM, 8/8/23 at 11:40 AM, 8/8/23 at 3:57 PM and 8/9/23 at 2:27 PM Resident 21 was observed receiving supplemental oxygen between 3.5 LPM and 4 LPM. On 8/9/23 at 2:27 PM Staff 18 (LPN) reviewed Resident 21's oxygen orders, observed Resident 21's oxygen flow settings at 4 LPM and confirmed the resident was to receive oxygen at 2 LPM. On 8/10/23 at 1:35 PM Staff 19 (Regional RN) stated he expected the nurses to administer Resident 21's oxygen at 2 LPM per the physician'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.
- Potential for harm · D2023-08-11 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review it was determined the facility failed to ensure residents were free from unnecessary medications for 1 of 6 sampled residents (#166) reviewed for medications. This placed residents at risk for adverse medication consequences. Findings include: Resident 166 was admitted to the facility in 5/2023 with diagnoses including diabetes and respiratory failure. Resident 166's 5/25/23 admission physician orders indicated the resident was to receive one Bactrim (antibiotic) tablet every Monday, Wednesday and Friday while on Prednisone 20 mg a day or higher dose. Resident 166's 5/2023 and 6/2023 MARs revealed the resident received one Bactrim tablet three times a day every Monday, Wednesday and Friday from 5/26/23 through 6/2/23 which exceeded the prescribed dosage. Starting 6/5/23, Resident 166 received one Bactrim (one time a day) every Monday, Wednesday and Friday until she/he was discharged from the facility. Resident 166's 5/25/23 through 6/8/23 Progress Notes revealed the resident had no adverse medication consequences due to receiving excessive doses…
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.
- Potential for harm · D2023-08-11 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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 interview and record review it was determined the facility failed to ensure records were accurate for 1 of 6 sampled residents (#166) reviewed for medications. This placed residents at risk for inaccurate medical records. Findings include: Resident 166 was admitted to the facility in 5/2023 with diagnoses including diabetes and respiratory failure. 1. Resident 166's 5/25/23 admission physician orders indicated the resident was to receive one Bactrim (antibiotic) tablet every Monday, Wednesday and Friday while on Prednisone 20 mg a day or higher dose. Resident 166's 5/2023 facility signed physician orders indicated the resident was to receive one Bactrim tablet three times a day every Monday, Wednesday, Friday while on Prednisone 20 mg a day or higher dose. On 8/10/23 at 11:51 AM Staff 3 (RNCM) reviewed Resident 166's 5/25/23 admission orders, the 5/2023 facility signed physician orders and the 5/2023 and 6/2023 MARs. Staff 3 confirmed Resident 166's admission orders were inaccurately transcribed and instructed staff to administer Bactrim three times a day instead of one…
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.
- Potential for harm · Dcited before2023-08-11 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 perform proper infection control practices for medical equipment and hand hygiene for 1 of 1 nurse reviewed during med pass. This placed residents at risk for infection and cross contamination. Findings include: The Centers for Disease Control and Prevention Best Practices for Assisted Blood Glucose Monitoring and Insulin Administration include: -Wear gloves during blood glucose monitoring and during any other procedure that involves potential exposure to blood or body fluids. -Perform hand hygiene immediately after removal of gloves and before touching other medical supplies intended for use on other persons. CDC's Guideline for Disinfection and Sterilization in Healthcare Facilities (2008) Medical equipment surfaces can become contaminated with infectious agents and contribute to the spread of health-care-associated infections. Noncritical medical equipment surfaces should be disinfected with an EPA-registered low- or intermediate-level disinfectant. Environmental surfaces (e.g., bedside…
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.
“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.
- 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.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to PACS GROUP — 274 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.9 | -0.9 vs chain |
| Health inspection | 2 of 5 | 2.5 | -0.5 vs chain |
| Staffing | 4 of 5 | 2.5 | +1.5 vs chain |
| Quality measures | 4 of 5 | 4.4 | -0.4 vs chain |
The other 273 homes this chain runs (chain average 2.9★, per CMS)
Showing 40 of 273; 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 / manager | Type | Role | Since |
|---|---|---|---|
| TRUIST BANK | Organization | 5% OR GREATER SECURITY INTEREST | since 09/01/2024 |
| APT, FREDERICK | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 05/10/2024 |
| CANO, PILO | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/29/2025 |
| JERGENSEN, JOSHUA | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 05/10/2024 |
| KEMPFER, GRETCHEN | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 12/16/2024 |
| MITCHELL, JOHN | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 05/10/2024 |
| MORRIS, CHRISTOPHER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/29/2025 |
| MILWAUKIE 12045 REALTY LLC | Organization | ADP OF THE SNF | since 09/01/2024 |
| PROVIDENCE ADMINISTRATIVE CONSULTING SERVICES INC | Organization | ADP OF THE SNF | since 09/01/2024 |
CMS files one row per role, so the 11 rows in the source record cover these 9 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.
3 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.
About 80% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $971K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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
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.
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 385136. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-13, 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.