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Robison Jewish Health Center

6125 SW Boundary Street, Portland, OR 97221 · For profit - Limited Liability company · 92 certified beds · (503) 535-4300 Medicare & Medicaid certified

Call the home — (503) 535-4300 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0605) — cited Sep 20253 actual-harm citations$48,520 in federal fines
Insights

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

In its favor
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 3 actual-harm citations
  • a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $48,520 in federal fines (most recent 2025-11-04)
  • 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.

2/5
CMS overall
2 of 5
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

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
5045 SW 77th Ave · (503) 297-1096 · Call to confirm hours
Pharmacy
5415 SW Beaverton Hwy · (503) 246-2842 · Call to confirm hours
Grocery
(503) 296-7220 · Call to confirm hours
Park
Vermont Hills Community Garden · Typically dawn to dusk
Place of worship
5815 SW Gilcrest Ct · (503) 245-4419

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 3 of 5
Short-stay residentsrehab / post-hospital 5 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.

Overall rating2★
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 increased25.5%14.9%15.4%worse
Long-stay residents who lose too much weight7.9%4.7%5.4%worse
Long-stay residents with a catheter left in their bladder0.4%1.4%0.9%better
Long-stay residents with a urinary tract infection0.0%2.0%2.0%better
Long-stay residents with depressive symptoms7.1%4.9%6.5%typical
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury3.5%2.4%3.3%typical
Long-stay residents whose ability to walk worsened17.6%20.6%16.1%typical
Long-stay residents on antianxiety or hypnotic medication14.6%12.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%95.2%95.3%typical
Long-stay residents with pressure ulcers5.5%5.8%4.7%worse
Long-stay residents with worsening bladder/bowel control24.2%21.8%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table13.6%13.9%17.1%better
Short-stay residents who newly got an antipsychotic medication0.2%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine98.2%81.2%79.4%better
Short-stay residents rehospitalized after admission22.2%21.4%22.6%typical
Short-stay residents with an outpatient ER visit14.5%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.

65.8% 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 75 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

65.8%U.S. median 51.5%
Got home and stayed home
10.3%U.S. median 10.7%
Went back to hospital
55.9%U.S. median 56.6%
Met the expected recovery
0.62U.S. median 0.31
Therapy hours / resident / day
0.35hours / resident / day
Physical therapy
0.21hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 55.9% 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 68 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 0.62 therapist hours per resident per day in 2026Q1 — more than 89% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 17% 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 SNF65.8%CMS range 55.3–74.151.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.3%CMS range 7.1–14.710.7%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 discharge55.9%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 discharge61.8%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge35.3%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified98.1%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care 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 discharge98.8%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 stay3.9%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 worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot 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 SNFs0.711.02Oct 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

0.71
RN hours/ resident / day
0.74
LPN hours/ resident / day
3.83
Aide hours/ resident / day
5.27
Total nurse hours/ resident / day
0.55
RN hoursweekends
49.5%
Total nursing turnover
78.6%
RN turnover

How full it usually is: this home is certified for 92 beds and averages 93.0 residents a day — about 101% occupied, or roughly -1 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.27 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.71 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.83 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.68 hrs/resident/day on weekends vs 5.51 on weekdays — 15% thinner on weekends. RN hours go from 0.77 to 0.55 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 50% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

9
deficiencies at the latest standard inspection (2025-09-22)
9
at the previous standard inspection (2024-08-02)

Deficiencies are unchanged from the previous inspection. 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.

32 citations, most serious first. The 13 most serious are shown; the remaining 19 are one tap away and print in full.

  • Actual harm · Gcited before2025-11-04 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review it was determined the facility failed to ensure a Stage 2 pressure ulcer was identified, assessed, treated and monitored upon admission to the facility for 1 of 3 sampled residents (#1) reviewed for pressure ulcers. As a result, Resident 1 experienced significant damage to her/his penis, which was unrepairable and resulted in the resident no longer being able to urinate from her/his penis. Findings include:Resident 1 admitted to the facility on 8/2025 with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, a foley catheter, and a Stage 2 pressure ulcer located on the resident's penis.Per CMS, a Stage 2 Pressure Ulcer is defined as a partial-thickness loss of skin 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. Granulation tissue, slough and eschar are 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
  • Actual harm · Gcited before2024-08-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to implement interventions to prevent a fall for 1 of 3 sampled residents (# 20) reviewed for accidents. This failure resulted in Resident 20 having a fall with serious injury including a head hematoma (a pool of blood under the skin), a gluteal hematoma, multiple rib fractures and skin avulsions (skin tears) which required emergency medical services and treatment at the hospital. Findings include: Resident 20 was admitted to the facility 12/2020 with diagnoses including dementia and anxiety. Resident 20's 12/10/23 Annual MDS indicated Resident 20 was noted to have wandering behavior and was exit seeking. A 4/17/24 Behavior and Psychotropic Meeting Note indicated Resident 20 exhibited wandering behaviors. Resident 20's 6/11/24 Quarterly MDS revealed she/he had severe cognitive impairment. A 6/18/24 Care Plan indicated Resident 20 had a pattern of wandering. A 7/9/24 Facility Incident Report revealed Resident 20 had an unwitnessed exit…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2023-04-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to safely transfer a resident with the use of a mechanical device for 1 of 1 sampled resident (#301) reviewed for accidents. This failure resulted in Resident 301 falling during a transfer and was hospitalized with a subdural hematoma (a pool of blood between the brain and its outermost covering). Findings include: Resident 301 was admitted to the facility in 11/2022 with diagnoses including atrial fibrillation. Resident 301's 11/7/22 Care Plan indicated the following: -The resident required assistance from two staff via a mechanical lift as necessary; and -The resident was on anticoagulant therapy (medicine to prevent blood clots). A 1/14/23 Progress Note revealed the resident slipped out of the sling connected to the mechanical lift and her/his head hit the floor. The resident sustained a bump to the back of her/his head as a result of the fall and was sent to the hospital. A review of the Resident 301's clinical record…

    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 · Fcited before2025-09-22 · 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

    Based on interview and record record it was determined the facility failed to monitor for legionella in 1 of 1 facility reviewed for infection control. This placed residents at risk for infection from exposure to water borne pathogens. Findings include:The facility's Infection Prevention and Control Program policy and procedure dated 10/1/25 indicated:- A water management program has been established as part of the overall infection prevention and control program, - Control measures and testing protocols are in place to address potential hazards associated with the facility's water systems, and- The Maintenance Director serves as the leader of the water management program. On 9/19/25 11:02 AM Staff 15 (Maintenance Technician) and Staff 39 (Maintenance Technician) stated that had not been trained on water borne pathogens and had not been instructed to monitor for legionella's presence in the facilities water system. On 9/19/25 at 11:13 AM Staff 40 (Maintenance Director) stated she was unaware of areas at risk for development of legionella in the facility and confirmed no monitoring…

    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 · E2025-09-22 · tag F0585 — failed to handle grievances — pattern
    Honor 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 ensure a system was in place to receive, track and resolve resident and/or resident representative grievances for 1 of 1 sampled facility reviewed for Resident Council. This placed residents at risk for unreported and unresolved grievances. Findings include:The facility's Grievance policy revised in April 2017 stated the following:- Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designed to hear grievances (e.g., the State Ombudsman).- The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. - The Administrator has delegated the responsibility of grievance and/or complaint investigation to the Grievance Officer who is the Social Services Coordinator.- Upon Receiving a grievance and complaint report, the Grievance Officer will begin an investigation into the allegations.- The Grievance Officer will record and maintain all grievances and…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-09-22 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    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 ensure physician orders were followed, and failed to identify, assess, and treat a change in a resident's skin condition for 3 of 9 sampled residents (#s 19, 84 and 87) reviewed for unnecessary medications and skin conditions. This placed residents at risk for adverse medication effects and untreated and worsening skin impairments. Findings include: 1.The facility's Medication Administration policy revised 10/1/24 stated the following:- Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. Resident 84 was admitted to the facility in 8/2025 with diagnoses including Multiple Myeloma (a cancer of white blood cells). Resident 84's 8/11/25 admission MDS indicated the resident had moderate cognitive impairment. Resident 84's 8/2025 and 9/2025 MAR indicated the resident was to receive:- Venetoclax (a cancer medication) 100 mg, four tablets at 9:00 AM and 11:00 AM daily. Do not crush; swallow one whole at a time with applesauce. A time stamped Medication…

    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 · Ecited before2025-09-22 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — 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 and only accessible to authorized persons for 1 of 4 Halls and 1 of 4 Households observed. This placed residents at risk for receiving unprescribed medications and drug diversion. Findings include: The facility's 10/2024 Medication Storage Policy revealed the following:-All drugs and biologicals will be stored in locked compartments, such as medication carts, cabinets, drawers, refrigerators and medication rooms.-Only authorized personnel will have access to the keys to locked compartments.-During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. 1. Resident 31 was admitted to the facility in 8/2025 with diagnoses including Parkinsonism unspecified (a group of symptoms that are similar to Parkinson's disease but do not have a definitive underlying cause). Resident 31's 9/2025 Physician Orders directed the resident to receive carbidopa-levodopa…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-09-22 · tag F0825 — pattern
    Provide or get specialized rehabilitative services as required for a resident.
    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 occupational and physical therapy services as ordered for 3 of 4 sampled residents (#s 11, 22 and 89) reviewed for rehabilitation services. This placed residents at risk for a decline in functional abilities and diminished quality of life. Findings include: The facility's Specialized Rehabilitative Services policy dated 10/2024 included the following: - The facility shall provide or obtain services from an outside resource for specialized rehabilitative services. These services will assist them in attaining, maintaining, or restoring their highest practicable level of physical, mental, functional, and psycho-social well-being. - Specialized rehabilitative services include but are not limited to physical therapy and occupational therapy. - Specialized rehabilitative services will be provided under the written order of a physician by qualified personnel. - Specialized rehabilitative services are considered a facility service and included within the scope of facility services. 1. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-22 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to maintain a homelike environment with comfortable sound levels and exercise reasonable care for the protection of resident's property from loss for 2 of 3 sampled residents (#s 5 and 87) reviewed for environment. This placed residents at risk for lack of a homelike environment, lost sleep and lost personal property. Findings include:1. The facility's 10/2024 Resident Personal Belongings Policy revealed the following: -The facility will exercise reasonable care for the protection of the resident's property from loss or theft. -All resident possessions, regardless of their apparent value to others, will be treated with respect. Resident 87 was admitted to the facility in 6/2025 with diagnoses including Parkinsonism unspecified (a group of symptoms that are similar to Parkinson's disease but do not have a definitive underlying cause). Resident 87's 7/4/25 admission MDS revealed the resident was cognitively intact. On 9/15/25…

    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 · D2025-09-22 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    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 psychotropic medications for 1 of 5 sampled residents (#8) reviewed for unnecessary medications. This placed residents at risk for experiencing adverse side effects of medication. Findings include: The facility's 10/2024 Use of Psychotropic Medication(s) Policy revealed PRN orders for psychotropic medications, excluding antipsychotics (a class of drugs used to treat mental health conditions such as schizophrenia and bipolar disorder), shall be limited to no more than 14 days, unless the attending physician or prescribing practitioner believes it is appropriate to extend the order beyond the 14 days. The medical record should include documentation from the physician or prescriber for the rationale for the extended time period and indicate a specific duration. Resident 8 was readmitted to the facility in 6/2025 with diagnoses including hip fracture. Resident 8's 6/3/25 Physician Orders directed the resident to receive lorazepam (a medication used to relieve…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-22 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    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 the state Long Term Care Ombudsman's office was notified of facility transfers or discharges for 2 of 2 sampled residents (#s 93, and 95) reviewed for hospitalization and discharge. This placed residents at risk for lack of advocacy. Findings include: 1. Resident 93 admitted to the facility in 7/2025 with diagnoses including aftercare following surgery and lower left leg cellulitis (bacterial infection of the skin).An 8/2/25 progress note indicated Resident 93 was transferred to the hospital for nausea and vomiting.A 9/22/25 review of Resident 93's medical chart did not reveal any notification to the LTCO's (Long Term Care Ombudsman) office regarding her/his transfer to the hospital.On 9/22/25 at 12:52 PM, Staff 2 (DNS) stated she was unaware who oversaw the notification to the LTCO's office for resident transfers.On 9/22/25 at 2:07 PM, Staff 1 (Administrator) stated she was unaware notifying the LTCO was a requirement for resident transfers.2. Resident 95 admitted to the facility in 6/2025 with…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-22 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review it was determined the facility failed to provide appropriate treatment and services to prevent further decreases in range of motion for 1 of 2 sampled residents (#49) 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:Resident 49 was admitted to the facility in 3/2022 with diagnoses including hemiplegia (a condition that causes paralysis or severe weakness on one side of the body). Resident 49's 7/2/25 Quarterly MDS revealed the resident was severely cognitively impaired and experienced upper extremity impairment on one side of her/his body.Resident 49's 7/23/25 Care Plan indicated the resident experienced contractures in her/his third, fourth and fifth fingers on her/his left hand and she/he was to work with RA to decrease the worsening of her/his contractures. Resident 49's 9/1/25 Physician Orders directed the following:-Staff were to place a contracture pillow…

    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 before2025-09-10 · 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 interview and record review it was determined, the facility failed to provide assistance with bathing for 1 of 3 sampled residents (#4) reviewed for bathing. This placed residents at risk of unmet care needs. Findings include:Resident 4 was admitted to the facility in 5/2025, with a diagnosis including stroke. Resident 4 was unable to be observed or interviewed as she/he no longer resided in the facility.Resident 4's 5/19/25 care plan indicated Resident 4 required maximum assistance with a Hoyer (a mechanical device used to transfer residents with limited mobility) and was dependent on one staff for showering twice weekly and as necessary.A review of Resident 4's 6/2025, 7/2025, and 8/2025 Task Charting revealed on 6/6/25, 6/20/25, 6/26/25, 8/8/25, and 8/15/25, bathing was documented as NA.(not applicable) by Staff 24 (CNA), Staff 25 (CNA), and Staff 26 (CNA). There was no evidence that a make-up shower was provided.On 9/8/25 at 4:17 PM, Staff 25 stated she charted NA for bathing on 8/8/25 for Resident 4 because she wasn't able to find someone to help get Resident 4 up…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 19 citations
  • Potential for harm · Dcited before2025-09-10 · 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 that the facility failed to ensure residents received treatment and care according to professional standards of practice related to neurological checks after a fall for 2 of 3 sampled residents (#s 5 and 6) reviewed for falls. This placed residents at risk for unmet care needs. Findings include: The Facility's 2025 Resident Fall Procedure Guidance revealed residents who experienced falls in the facility were to be placed on neurological checks (neuro checks) for 72 hours to monitor any changes of condition or altered cognitive status. Each neuro check was to be documented in the Neuro Check Binder at the nurse's station until the 72-hour mark had been reached.1. Resident 5 was admitted to the facility in 8/2025, with diagnoses including joint replacement surgery.Resident 5's 8/23/25 Care Plan revealed the resident had self-care performance deficits with activities of daily living due to her/his joint replacement surgery. Resident 5's 8/23/25 Fall Risk Evaluation rated Resident 5 as a high fall risk.An Incident…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-05 · tag F0557 — isolated
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    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 treated with dignity and respect for 1 of 2 sampled residents (#1) reviewed for dignity and respect. This placed residents at risk for decreased quality of life. Findings include: Resident 1 admitted to the facility in 10/2021, with diagnosis including acute cerebrovascular insufficiency (a condition where blood flow is reduced in the brain causing damage). Resident 1's 1/24/23 Care Plan revealed the resident with a communication and ADL self-care performance deficit related to cognitive impairment and left sided weakness. Facility interventions included adequately timed and non-rushed guided care, ensuring a safe environment through eye contact and continuous face to face verbal communication and cues when providing peri-care. A video recorded incident report dated 1/5/25 revealed the following: Resident 1 was observed through an observational security camera receiving cares from Staff 4 (CNA). Staff 4 was viewed while providing peri-care grabbing Resident 1's groin…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-08-02 · tag F0725 — failed to have enough nursing staff — widespread
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to ensure there was sufficient nursing staff available to provide the necessary care and services to meet residents' needs in 1 of 1 facility reviewed for staffing. This placed residents at risk for unmet care needs. Findings include: The facility's revised 4/2007 Staffing Policy indicated the facility provided adequate staffing to meet the needed care and services of the residents. On 7/29/24 the facility had a census of 39 residents in four houses (each house was a self-contained unit). On 8/2/24, Staff 2 (DNS) provided a list of residents who: -Required two-person mechanical lift transfers: 13; -Required one or two-person extensive or total assistance for bathing: 24; -Required one or two-person extensive or total assistance for toileting: 29; -Required one or two-person extensive or total assistance for dressing: 30; -Required two person assistance at all times for all care: 2; -Had behavioral healthcare needs which required monitoring: 7; -Were at risk for elopement: 2; -Were considered high fall risks:…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-08-02 · 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, interview and record review it was determined the facility failed ensure the ice machine was cleaned adequately to maintain sanitary conditions in 1 of 1 kitchen reviewed for sanitary kitchen services. This placed residents at risk of foodborne illness. Findings include: On 7/29/24 at 9:49 AM the facility's ice machine located adjacent to the dry storage area and non-meat side of the kitchen was observed to have a powdery gray/green substance accumulated in the grooves of the panel directly above supply of ice. Condensation dripped across the panel's grooves and onto the supply of ice. Staff 29 (Executive Chef/Director of Dining Services) acknowledged the presence of the powdery substance and stated, It should not be like that and should be cleaned. A review of the Ice Machine Cleaning Log posted adjacent to the ice machine revealed staff cleaned the machine on a monthly basis. The task of cleaning the ice machine was not indicated in the kitchen's weekly Deep Cleaning Schedule or Daily Cleaning Schedule. On 8/2/24 at 11:48 AM Staff 29 stated she expected 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-08-02 · 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

    Based on observations, interviews and record review it was determined the facility failed to implement infection control practices for 18 of 18 residents (#s 2, 4, 5, 8, 9, 10, 11, 14, 18, 21, 25, 26, 27, 29, 31, 33, 34 and 36) and 1 of 4 staff (# 15) reviewed for infection control. This placed residents at risk for infection. Findings include: 1. The Center for Disease Control and Prevention (CDC) website section titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDROs) specified enhanced barrier precautions (EBP) include the use of gowns and gloves during high contact resident care activities when a resident has a wound or an indwelling medical device such as an urinary catheter. Examples of high contact resident care activities requiring gown and glove use for EBPs include: - Dressing - Bathing/showering - Transferring - Providing hygiene - Changing linens - Changing briefs or assisting with toileting - Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator -…

    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 · Ecited before2024-08-02 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined the facility failed to ensure drugs and biologicals were secured and not expired for 3 of 4 medication carts and 1 of 1 medication room reviewed for medication storage. This placed residents at risk for adverse medication effects. Findings include: The facility Storage of Medication policy statement dated April 2007, stated The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. 1. On 8/1/24 at 11:06 PM the treatment cart on the [NAME] Hall was observed to be unlocked and unattended by staff. On 8/1/24 at 11:31 PM Staff 16 (RN) confirmed she left the treatment cart unlocked and unattented. 2. On 7/31/24 at 8:13 AM Staff 10 (LPN)…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-02 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and record review it was determined the facility failed to develop and implement person centered care plans for 2 of 8 residents (#s 3 and 8) reviewed for falls and medications. This placed residents at risk for falls and adverse medication effects. Findings include: 1. Resident 3 was admitted to the facility in 5/2021 with diagnoses including congestive heart failure. A 5/26/24 Fall Risk Evaluation determined Resident 3 to be at a moderate risk for falls. A 6/14/24 Care Plan identified Resident 3 at a moderate risk for falls with interventions including placing her/his bed in a low position to decrease the risk of injuries from falls. On 7/31/24 at 10:03 AM Resident 3 was observed asleep in bed with the bed at a normal height. On 7/31/24 at 10:09 AM Staff 30 (CNA) stated Resident 3 was not at risk for falls and was not aware of interventions in place regarding bed positioning to reduce the risk for falls. On 7/31/24 at 11:30 AM Staff 4 (RNCM) stated Resident 3's care plan including having her/his bed in a low position. Staff 4 observed Resident 3's…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-02 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to follow physician orders for medication administration for 1 of 5 residents (#26) reviewed for unnecessary medications. This placed residents at risk for medical complications. Findings include: Resident 26 admitted to the facility in 10/2021 with diagnoses including paroxysmal atrial fibrillation (irregular heart beat), hemiplegia as result of a stroke (loss of function of one side of the body) and high blood pressure. A 7/22/22 Physician Order included 5 mg of apixaban (a medication used to prevent blood clotting) to be administered two times a day for paroxysmal atrial fibrillation. Review of 6/2024 and 7/2024's MARs revealed apixaban was documented as refused on the following dates and times: - 6/1/24 in the morning, - 6/14/24 in the evening, - 6/16/24 in the evening, - 6/17/24 in the evening, - 6/18/24 in the evening, - 6/28/24 in the evening, - 6/29/24 in the evening, - 6/30/24 in the evening, - 7/2/24 in the evening, - 7/5/24 in the evening, - 7/10/24 in the evening, - 7/12/24 in the evening, -…

    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 · D2024-08-02 · tag F0712 — isolated
    Ensure that the resident and his/her doctor meet face-to-face at all required visits.
    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 residents were seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter for 1 of 5 sampled residents (#8) reviewed for medications. This placed residents at risk for unassessed needs. Findings include: Resident 8 was admitted to the facility in 7/2023 with diagnoses including atrial fibrillation (a type of irregular heartbeat that causes the heart to beat too fast). A review of Resident 8's health record indicated there were no physician visits documented since his/heradmission. Staff 4 (RNCM) on 8/1/24 at 2:54 PM he/she stated Resident 8 had not been seen by their primary care physician since the time of admission. Staff 2 (DNS) on 8/2/24 at 11:13 AM stated the facility policy was for residents to have been seen by the physician every 30 days for 90 days, and every 60 days thereafter. She verified Resident 8 had not been seen by her physician since his/her admission 7/2023.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-02 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 expired COVID-19 immunizations were not administered to 2 of 11 residents (#s 19 and 36) reviewed for immunizations. This placed residents at risk for adverse immunization consequences. Findings include: 1. Resident 19 admitted to the facility in 9/2022 with diagnoses including congestive heart failure. The [DATE] Quarterly MDS indicated Resident 19 had moderately impaired cognition. A [DATE] Event Progress Note indicated Resident 19 received an expired COVID-19 vaccine on [DATE]. Resident 19 was placed on alert charting and monitored for adverse side effects. On [DATE] at 2:08 PM Staff 8 (RN) stated she was distracted when she administered the COVID-19 vaccine to Resident 19 and did not check the expiration date prior to administering the vaccine. On [DATE] at 3:23 PM Staff 2 (DNS) stated it was her expectation the expired vaccines were disposed of in a timely manner. 2. Resident 36 admitted to the facility in 11/2023 with…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-04-21 · 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, interview and record review it was determined the facility failed to ensure food was prepared and served under sanitary conditions for 1 of 1 kitchen reviewed for kitchen services. This placed residents at risk of cross contamination and foodborne illness. Findings include: 1. On 4/20/23 at 11:43 AM Staff 14 (Meat Cook) was observed in the meat kitchen without a hair restraint while slicing meat. At 11:50 AM Staff 15 (Line Cook) was observed in the tray line kitchen without hair restraints on his head or beard while placing trays of cooked carrots and mashed potatoes on the steam table for lunch service. Staff 13 (Executive Chef/Director of Dining Services) was present during these observations and acknowledged both staff members were not wearing hair restraints. She confirmed it was her expectation staff should wear hair restraints while handling food. 2. On 4/21/23 at 8:56 AM the ice machine adjacent to the dry storage and non-meat side of the kitchen was observed to have a grey/green slimy substance in the creases of a plastic shield inside the machine.…

    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 · Dcited before2023-04-21 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined the facility failed to provide a homelike environment for 1 of 4 units (200, 300, 400 and 500 units) reviewed for environment. This placed residents at risk for living in an unhomelike environment. Findings include: From 4/17/23 through 4/20/23 between the hours of 8:00 AM and 4:00 PM, the following observations were made on the 400 unit: -Two arm chairs, one to the right of the fireplace and one across from the television in the main gathering area, had brownish stains on both arms and the seat of the chairs. -room [ROOM NUMBER] had several dark, discolored spots on the carpet in the center of the room. -room [ROOM NUMBER] had an approximate eight inch by six inch area gouged from the wall at the head of the bed that needed repairing and painting. -room [ROOM NUMBER] had an approximate one foot in diameter dark, discolored stain on the carpet between the bed and the window. -room [ROOM NUMBER] had multiple dark brown/black spots on the carpet from the door 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-21 · tag F0636 — isolated
    Assess 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to comprehensively assess the dental health of 1 of 1 resident (#20) reviewed for dental care needs. This placed residents at risk of unmet dental needs. Findings include: Resident 20 was admitted to the facility in 2018 with primary diagnoses including quadriplegia (paralysis affecting a person's limbs and body from the neck down). On 4/18/23 at 10:11 AM Resident 20 was observed to have missing teeth and reported she/he had a broken lower molar. Resident 20 reported caregivers provided assistance to brush her/his teeth once a week at best and stated her/his teeth and gums hurt when they were brushed. A review of Resident 20's most recent Annual MDS assessment dated [DATE] revealed she/he had no obvious or likely decay or broken natural teeth. On 4/19/23 at 12:40 PM Resident 20 stated nursing staff did not look in her/his mouth to assess her/his teeth. On 4/21/23 at 10:40 AM Staff 16 (MDS Coordinator) stated she 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-21 · 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 interview and record review it was determined the facility failed to provide necessary care and services related to showering for 1 of 4 sampled residents (#2) reviewed for ADLs. This placed residents at risk for unmet hygiene needs. Findings include: Resident 30 was admitted to the facility in 2/2022 with diagnoses including dementia. Resident 30's 2/22/23 Annual MDS indicated the resident required extensive assistance with one person physical assist for showering/personal hygiene. Resident 30's 3/23/23 through 4/16/23 showering task logs indicated the resident received showers on Sunday evenings and Thursday mornings. Resident 30's showering task logs indicated the following: -3/23: resident refused; -3/25: shower completed; -3/30: not applicable; -4/2: not applicable; -4/6: not applicable; -4/8: shower completed; -4/9: shower completed; -4/12: shower completed; -4/13: not applicable; -4/15: shower completed. Resident 30 was not showered from 3/25/23 until 4/8/23 for a total of 13 days. On 4/17/23 at 2:14 PM Resident 30 stated she/he was suppose to receive showers twice a…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-21 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to provide timely notification to a resident's physician of a missed seizure medication dose for 1 of 7 sampled residents (#151) reviewed for medications. This placed residents at risk for adverse consequences of missed medication doses, including seizures. Findings include: Resident 151 was admitted to the facility on [DATE] at 2:45 PM with diagnoses including epilepsy, a disorder in which nerve cell activity in the brain is disturbed, causing seizures. Resident 151's 8/2/22 Physician Orders included lacosamide (a medication used to treat seizures) twice daily related to seizure management. An 8/2/22 at 10:09 PM Progress Note revealed the lacosamide was not administered as the medication was not available and the pharmacy was contacted. An 8/3/22 at 7:10 AM Progress Note indicated the nurse spoke with a pharmacy technician who stated the lacosamide was on back up and the pharmacy was waiting for another manufacturer to deliver the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-21 · 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 interview and record review it was determined the facility failed to consistently assess pressure ulcers and notify the physician of a new pressure ulcer for 1 of 2 sampled residents (#47) reviewed for pressure ulcers. This placed residents at risk for worsening or delayed healing of pressure ulcers. Findings include: Resident 47 was admitted to the facility in 3/2023 with diagnoses including neck fracture and a deficit in cognition and communication. Resident 47's 3/10/23 admission MDS indicated the resident was moderately cognitively impaired, did not have a pressure ulcer and was at risk for developing pressure ulcers. The MDS indicated she/he had a pressure reducing device for her/his chair and bed, was on a turning/repositioning program, and had nutrition or hydration intervention to manage skin problems. Resident 47's 3/10/23 Pressure Ulcer/Injury CAA indicated the resident was at risk for developing pressure ulcers related to impairment in ADLs and incontinence. The CAA indicated a licensed nurse would assess the resident's skin each week and the physician would be…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-21 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    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 monitor nutritional parameters for 1 of 1 sampled residents (#47) reviewed for change of condition. This placed residents at increased risk of unplanned weight loss. Findings include: Resident 47 was admitted to the facility in 3/2023 with diagnoses including neck fracture and a deficit in cognition and communication. Resident 47's 3/4/23 Care Plan indicated the resident was at increased nutritional risk related to variable oral intake and weight loss noted since admission. Nutritional interventions included: -Fluid enhancement program to promote hydration; -Monitor daily intakes; -Monitor weights per orders; and -Nutritional supplements as ordered. Resident 47's 3/2023 Physician Orders revealed the resident received a nutrient dense supplement drink twice daily, weighed daily for the first three days and then weekly. A review of Resident 47's clinical record revealed the following weights: -3/4/23: refused; -3/5/23: refused; -3/6/23: 152.1 lbs; -3/7/23: no weight recorded or progress note made; -3/14/23:…

    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 before2023-04-21 · tag F0725 — failed to have enough nursing staff — isolated
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs in a timely manner for 2 of 8 residents (#s 2 and 40) reviewed for staffing concerns. This placed residents at risk for delayed and unmet care needs. Findings include: 1. Resident 2 was admitted to the facility in 2021 with diagnoses including asthma and diabetes. Resident 2's 11/29/22 Annual MDS revealed the resident was cognitively intact. Resident 2's Care Plan for ADL performance (last revised 3/14/23) indicated the resident required extensive assistance with two staff for bed mobility, dressing, toileting, transfers and personal hygiene. Resident 2's 4/5/23 through 4/19/23 [NAME]-Care (call light tracking records) indicated the following delayed call light response times: -Call light response times between 20 minutes and 30 minutes: 12 -Call light response times between 31 minutes and 45 minutes: 5 -Call light response times between 46 minutes and one hour: 1 -Call light…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-21 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to ensure residents were free from unnecessary bowel medications for 1 of 5 sampled residents (#7) reviewed for unnecessary medications. This placed residents at risk for loose stools and diarrhea. Findings include: Resident 7 was admitted to the facility in 12/2022 with diagnoses including stroke and acute respiratory failure (lack of oxygen). Resident 7's 12/9/22 admission MDS indicated Resident 7 had severe cognitive deficits. A review of Resident 7's 3/20/23 through 4/18/23 MAR indicated an order for Senna (a laxative and stool softener) which was administered twice a day for constipation. The order indicated to hold the medication if Resident 7 had loose stools. The MAR indicated Resident 7 was administered Senna twice daily and there were no instances when the medication was held. A review of Resident 7's Bowel Elimination Flowsheets from 3/20/23 through 4/18/23 indicated Resident 7 had loose stools on 3/23, 3/24, 3/25, 3/26, 3/27, 3/28, 3/29, 3/30, 3/31, 4/1, 4/8, 4/11, 4/13, 4/14 and 4/17. On 4/19/23…

    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

$48,520 in federal fines across 2 penalties.

  • $37,681 — penalty dated 2025-11-04
  • $10,839 — penalty dated 2024-08-02

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

Who owns this facility

Owner / managerTypeRoleShareSince
SCHMUKLER HOLDINGS, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 10/01/2024
SCHMUKLER, YEHUDAIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL100%since 10/01/2024
BULES, CLAUDIAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2025
VELLODY, NITAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2025

CMS files one row per role, so the 8 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner 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.

$9.1M
Net patient revenuemost recent cost report
-31.0%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 57%Medicare 4%Other / private 39%

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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

$721per resident / day
operating cost
$21,907per month
≈ monthly operating cost
$550per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). 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 385145. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-22, 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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