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West Hills Health & Rehabilitation

5701 SW Multnomah Blvd, Portland, OR 97219 · For profit - Partnership · 180 certified beds · (503) 244-1107 Medicare & Medicaid certified

Call the home — (503) 244-1107 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)$12,659 in federal fines
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • 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
Worth asking about
  • inspectors recorded 1 serious finding 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 (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $12,659 in federal fines (most recent 2023-12-18)
  • its facility-reported quality-measure score sits well above its independent inspection score

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

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

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

Worth a closer look. This home's quality-measure rating runs 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 — 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
4411 SW Vermont St · (503) 494-9992 · Call to confirm hours
Pharmacy
4411 SW Vermont St · (503) 494-2098 · Call to confirm hours
Grocery
8927 SW 57th Ave · (800) 457-5672 · Call to confirm hours
Park
5740 SW Miles St · (503) 823-2223 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 4 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 improved from 3 to 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased6.4%14.9%15.4%better
Long-stay residents who lose too much weight8.7%4.7%5.4%worse
Long-stay residents with a catheter left in their bladder1.2%1.4%0.9%worse
Long-stay residents with a urinary tract infection1.2%2.0%2.0%better
Long-stay residents with depressive symptoms2.5%4.9%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury0.0%2.4%3.3%check this — see note marked star below the table
Long-stay residents whose ability to walk worsened10.9%20.6%16.1%better
Long-stay residents on antianxiety or hypnotic medication20.1%12.4%18.9%typical
Long-stay residents given the seasonal flu vaccine91.0%95.2%95.3%typical
Long-stay residents with pressure ulcers3.3%5.8%4.7%better
Long-stay residents with worsening bladder/bowel control21.8%21.8%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table15.9%13.9%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.3%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine93.1%81.2%79.4%better
Short-stay residents rehospitalized after admission21.9%21.4%22.6%typical
Short-stay residents with an outpatient ER visit9.0%16.1%12.0%better

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

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

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

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

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

66.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 272 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

66.6%U.S. median 51.5%
Got home and stayed home
9.6%U.S. median 10.7%
Went back to hospital
66.2%U.S. median 56.6%
Met the expected recovery
0.40U.S. median 0.31
Therapy hours / resident / day
0.21hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 66.2% 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 0.40 therapist hours per resident per day in 2026Q1 — more than 69% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 20% 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 SNF66.6%CMS range 61.4–72.151.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.6%CMS range 7.4–12.510.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge66.2%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 discharge54.4%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 discharge52.9%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 identified98.9%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.1%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.3%CMS range 3.8–10.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.771.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.60
RN hours/ resident / day
1.14
LPN hours/ resident / day
3.30
Aide hours/ resident / day
5.03
Total nurse hours/ resident / day
0.39
RN hoursweekends
41.5%
Total nursing turnover
42.9%
RN turnover

How full it usually is: this home is certified for 180 beds and averages 94.5 residents a day — about 52% occupied, or roughly 86 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.03 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.60 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.30 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 4.39 hrs/resident/day on weekends vs 5.29 on weekdays — 17% thinner on weekends. RN hours go from 0.68 to 0.39 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 42% is about the same as the national median of 45%.

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

Inspection trend

3
deficiencies at the latest standard inspection (2025-04-25)
16
at the previous standard inspection (2023-12-18)

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.

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.

26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.

  • Actual harm · Gcited before2023-12-18 · 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 administer medication as ordered for 1 of 6 sampled residents (#485) reviewed for medication administration. This failure resulted in an increased potassium level and required Resident 485's hospitalization. Findings include: On 6/14/23, the Past Noncompliance was corrected when the facility completed a root cause analysis of the incident and staff were trained on steps to take if a medication was thought to be missing which included: -Performing a thorough search of all med carts and the med room including the refrigerator to find the missing medication. -Placing notes on or in the med cart to advise oncoming workers of a medication's location. -Providing detailed documentation of why the medication was not given beyond only writing unavailable. -Notifying the provider and documenting when the provider was notified. According to the National Library of Medicine, revised 6/20/23, the normal range for potassium is 3.7 milliequivalent…

    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 · Past Non-Compliance
  • Potential for harm · Fcited before2025-04-25 · 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 proper personal hygiene practices and safe food storage handling techniques for 1 of 1 facility kitchen and 2 of 2 facility ice machines reviewed for kitchen sanitation. This placed residents at risk for cross contamination and foodborne illnesses. Findings include: On 4/21/25 at 9:50 AM, Staff 29 (Cook) was observed to have head and facial hair exposed with no facial and head hair restraints. Staff 30 (Cook) was observed to have with facial hair exposed and no facial hair covering. Staff 29 and Staff 30 were actively prepping the lunch meal. On 4/21/25 at 10:20 AM, Staff 8 (AM Dining Services Director) acknowledged hair and beard nets were to be worn at all times when working in the kitchen. She stated the facility provided hair restraints for all staff. On 4/23/25 at 11:10 AM, Staff 7 (PM Dining Services Director) was observed to pick up a pen off the floor and then changed her gloves without performing hand hygiene. Staff 7 confirmed she did not wash her hands after removing her…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-25 · tag F0554 — isolated
    Allow 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 for safe self-administration of medications for 1 of 1 sampled resident (#293) reviewed for self-administration of medications. This placed residents at risk for unsafe medication administration. Findings include: The facility's Self-Administration of Medications policy, dated 11/20/16, revealed: A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. Resident 293 admitted to the facility in 4/2025 with diagnoses including spinal stenosis (a condition were the spaces within the spine narrow). A review of Resident 293's record revealed there was no assessment for Resident 293 to self-administer medications. On 4/21/25 at 9:57 AM Resident 293 was observed alone in her/his room with a small cup on her/his bedside table, the cup contained multiple medications. On 4/21/25 at 12:23 PM Resident 293 was in her/his room, the same cup with medications was on the 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-25 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to obtain information related to advance directives and health care decisions for 3 of 3 sampled residents (#s 45, 62 & 392) reviewed for advance directives. This placed residents at risk for not having health care decisions honored. Findings include: a. Resident 45 admitted to the facility in 2/2025 with diagnosis including chronic inflammatory demyelinating polyneuritis (an autoimmune disease that leads to weakness). Resident 45's care plan initiated 4/24/25 indicated advance directives are in effect, and they will be carried out in accordance with the wishes on an ongoing basis. A 2/26/25 care conference note indicated an advanced directive was reviewed. A review of Resident 45's clinical record found no advanced directive. During an interview on 04/22/25 11:45am Resident 45 stated she/he had not completed an advanced directive. During an interview on 4/23/24 at 2:31pm Staff 11 (Social Services Coordinator) stated Resident 45 did not have an advanced directive on file, could not remember whether 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-11 · tag F0624 — isolated
    Prepare residents for a safe transfer or discharge from the nursing home.
    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 education and training for the self-administration of an anticoagulant subcutaneous medication prior to discharge for 1 of 3 sampled residents (#2) reviewed for discharge. This placed residents at risk for an unsafe discharge. Findings include: The 10/14/24 Facility Discharge Planning Policy stated it is the facility's responsibility to develop and implement an effective discharge planning process that focused on the resident's discharge goals, and the preparation of residents to be active partners so they may be effectively transitioned into post-discharge care to prevent readmissions. This included an evaluation of the resident's discharge needs, the development of a final discharge plan, and continuous education to be provided to the resident and the resident's family to ensure any unnecessary delays in the resident's care post discharge. Resident 2 was admitted to the facility in 2024, with diagnosis including left femur fracture and stroke. Resident 2's Care Plan revealed the resident received…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-11 · 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

    Based on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 3 sampled residents (#5) reviewed for medication administration. This placed residents at risk for adverse medication consequences. Findings include: The Facility's 10/14/24 Medication Administration Procedure revealed the following: Medication Incidents are to be reported to the Director of Nurses so that an investigation can be initiated. Medication incidents are incidents where medication is omitted from the order, administered to the incorrect resident, provided with the wrong dosage, form, route or time of administration, and/or provided with unprescribed medications. When the incident is made, the person committing the incident shall: - Notify the nurse of the resident (if this incident is made by the nurse, then the supervisor or DON is to be notified immediately). - Complete a medication incident form when appropriate which will go directly to the DNS and the ED. - Notify the MD, family, and relay physician response. - 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-05-09 · tag F0802 — failed to prepare enough nourishing food — widespread
    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to ensure sufficient dietary staff were available to ensure food service was delivered in a timely manner for 1 or 1 kitchens reviewed. This placed residents at risk for unmet nutritional needs. Findings include: A public complaint was made to the state agency on 10/9/23 which alleged all meals were served late daily and timeliness had been an issue for several months. Witness 2 (Complainant) stated meals were served hours after the posted times and residents complained to staff their meals were late. On 5/1/24 at 2:51 PM, the Resident Council President stated the food was always served late and at times was cold. On 5/7/24 at 11:30 AM, Staff 10 (Cook) stated the dining room was served meals first, then east hall due to several residents who required one to one assistance with eating, then west hall and lastly, the skilled hall. Staff 10 stated there were staffing shortages in the facility. On 5/8/24 at 1:15 PM, Staff 5 (CNA) stated there was a shortage of dietary staff last fall and CNA's were told meals…

    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 · D2024-05-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to implement care plan interventions to ensure adequate supervision was provided to prevent accidents for 1 of 3 sampled residents (#100) reviewed for hot beverage safety. This placed residents at risk for accidents. Findings include: Resident 100 was admitted to the facility in 2020 with diagnoses including encephalopathy (a disturbance of brain function) and dementia. Resident 100's care plan dated 3/22/23, revealed she/he was on an altered diet and required one to one supervision for meals to encourage intake. A care plan revision dated 4/11/23, noted that staff were not to leave cups in front of her/him without supervision. On 3/27/23 the facility submitted a report to the state agency which revealed Resident 100 was given a hot cup of tea on 3/26/23. Resident 100 picked up the cup, dropped it and some of the hot liquid splashed on her/his left thigh which resulted in a first degree burn. Resident 100 was not interviewed due to she/he was discharged from the facility. On 5/8/24 at 1:15 PM, Staff 5 (CNA)…

    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 · D2024-05-09 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    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 meals were served in a palatable and at appetizing temperatures for 2 of 2 sampled residents (#s 105 and 106) reviewed for food. This placed residents at risk for unmet nutritional needs. Findings include: The facility's Food Temperature policy, revised 8/2023, noted food should be transported as quickly as possible to maintain temperatures for delivery and service. The facility's 3/2024 Resident Council notes documented the food is always cold and tasteless, have to ask for coffee 2X (two times) because it's cold and portions are inconsistent. Resident 105 was admitted to the facility in 2022 with diagnoses including acute cystitis (bladder infection) and weakness. On 5/1/24 at 3:16 PM, Resident 105 stated the food was terrible and she/he usually ate peanut butter and jelly sandwiches for lunch and oatmeal and cinnamon rolls for dinner. She/he stated the scalloped potatoes were hard and most meals were not…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-12-18 · 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 review, it was determined the facility failed to develop and implement a water management program and conduct a risk analysis assessment for potential areas of growth and spread of waterborne pathogens for 1 of 1 facility reviewed for infection control. This placed all residents at risk for exposure to waterborne pathogens. Findings include: On 12/14/23 at 9:53 AM Staff 20 (Maintenance Director) confirmed he was in charge of the facility's legionella program and reported he did not receive any training on how to protect the facility from waterborne pathogens such as legionella. He also stated was not aware of the need to complete a thorough analysis of the facility's water systems to identify and address the risk of waterborne pathogens such as legionella. Staff 20 reported he did not know where to find a water flow chart that would help to identify problem areas within the facility's system. He added, It's probably in a set of plans somewhere. Staff 20 confirmed he tested water temperatures but did not complete any other testing of the facility's water…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-12-18 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
    Reasonably accommodate the needs and preferences of each 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 ensure resident needs and preferences related to showers and lighting were accommodated for 4 of 6 sampled residents (#s 3, 4, 21 and 440) reviewed for ADLs and accommodation of needs. This placed residents at risk for lack of personal hygiene, an unhomelike environment and not honoring preferences. Findings include: The facility's 10/22/23 Accommodation of Needs policy indicated: -The facility would assist residents in maintaining or achieving independent functioning, dignity and well-being to the extent possible. -The facility would make efforts to reasonably accommodate the needs and preferences of the resident. 1. Resident 4 was admitted to the facility in 2/2021 with diagnoses including multiple sclerosis (a progressive neurological disease). Resident 4's 9/27/23 Quarterly MDS revealed she/he had moderate cognitive impairment, required total assistance for bathing/showering and had no rejection of care. An 11/15/23 Progress Note written by Staff 15 (LPN) indicated Resident 4 refused…

    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
Show the remaining 15 citations
  • Potential for harm · E2023-12-18 · tag F0725 — failed to have enough nursing staff — pattern
    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 sufficient staffing to meet resident care needs and to ensure resident call lights were answered timely for 1 of 1 facility and 3 of 4 sampled residents (#s 2, 68 and 71) reviewed for sufficient nurse staffing. This placed residents at risk for unmet care needs and lengthy call light response times. Findings include: 1. Resident 2 was admitted to the facility in 7/2022 with diagnoses including dementia. Resident 2's 11/1/23 through 12/12/23 call light tracking records indicated the following delayed call light response times: -Call light response times between 20 minutes and 30 minutes: 7 -Call light response times between 31 minutes and 45 minutes: 2 -Call light response times between 46 minutes and one hour: 2 On 12/14/23 at 8:41 AM Witness 3 (Family) reported the facility did not have enough staff which resulted in long call light response times and Resident 2 sitting in soiled garments for extended periods of time. On 12/18/23 at 10:09 AM Staff 1 (Executive Director) reported the facility…

    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 · E2023-12-18 · tag F0745 — failed to provide medically-related social services — pattern
    Provide medically-related social services to help each resident achieve the highest possible quality of life.
    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 medically related social services were provided to support residents' individual needs through the assessment process and obtain personal items for 1 of 2 sampled residents (#21) reviewed for communication needs. This placed residents at risk for unmet needs and decreased dignity. Findings include: Resident 21 was admitted to the facility in 11/2023 with diagnoses including lower back fracture. Resident 21's 11/17/23 Trauma Screening Tool indicated the resident experienced multiple traumas, including physical assault and combat or exposure to a war zone. Resident 21's 11/20/23 admission MDS indicated the resident's preferred language was Russian, the resident wanted an interpreter to communicate with health care staff and the resident did not experience any difficulties with communication. The BIMS, Staff Assessment for Mental Status, Resident Mood Interview and Staff Assessment of Resident Mood were all marked as not assessed. The Psychosocial Well-Being CAA indicated doing her/his…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-12-18 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 resident personal refrigerators were free of expired and/or unlabeled foods for 1 of 5 residential halls and dishwasher water temperature was monitored for 1 of 1 kitchen reviewed for food safety and sanitation. This placed residents at risk for food-bourne illness. Findings include: 1. On 12/11/23 at 11:28 AM Resident 15's personal refrigerator was observed to have a turkey sandwich dated 12/2/23, an undated ham and cheese sandwich, three small containers of undated and unlabeled ranch dressing, one container of mayonnaise with a use by date of 12/5/23 and four containers of peach yogurt with a use by date of 12/5/23. On 12/11/23 at 11:35 AM Staff 19 (CMA/CNA) stated the items should have been dated or thrown away. On 12/11/23 at 11:49 AM Resident 14's personal refrigerator was observed to have a small container of orange juice dated 11/3/23, a small container of Kool Aid gel snack dated 5/17/23, a small container…

    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 · D2023-12-18 · 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 maintain a homelike environment for 1 of 1 facility reviewed for environment. This placed residents at risk for living in an unkempt environment. Findings include: Observations of the facility's general environment and residents' rooms from 12/11/23 through 12/18/23 identified the following issues: -Rooms 106, 121, 127, 129 and 134 had wood wall protectors behind resident beds that were chipped with sharp/jagged edges and missing paint. -room [ROOM NUMBER] had a screen door that lead to the patio area with the door off the tracks that was unable to open or close properly. -room [ROOM NUMBER] had an approximate three inch piece of wood missing on the resident door with sharp/jagged edges. -room [ROOM NUMBER] had a missing transition strip from the hall to the room exposing a gap in the flooring which was not a cleanable surface. -Ceiling tiles in the library had a green/brown substance on them above the fish tank. -A wall near room [ROOM…

    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 · D2023-12-18 · 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

    Based on interview and record review it was determined the facility failed to comprehensively assess cognitive abilities and mood state for 1 of 2 sampled residents (#21) reviewed for communication. This placed residents at risk for unassessed needs. Findings include: Resident 21 was admitted to the facility in 11/2023 with diagnoses including lower back fracture. Resident 21's 11/20/23 admission MDS indicated the resident's preferred language was Russian, the resident wanted an interpreter to communicate with health care staff and the resident did not experience any difficulties with communication. No evidence was found in Resident 21's clinical record to indicate her/his cognitive abilities or mood state was assessed. On 12/13/23 at 9:03 AM and on 12/14/23 at 9:18 AM an interview was conducted with Resident 21 with the use of a translation service. Resident 21 stated staff did not regularly use the translator service when interacting with her/him nor had anyone from the facility asked her/him about her/his mood. Resident 21 further stated she/he was sad all of the time because of…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-18 · 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 interview and record review, it was determined the facility failed to develop a person-centered comprehensive care plan for 1 of 2 sampled residents (#10) reviewed for respiratory care. This placed residents at risk for unmet needs. Findings include: Resident 10 was readmitted to the facility in 10/2022 with diagnoses including tracheostomy (an artificially created opening in the windpipe to help air reach the lungs) status. Resident 10's 10/2023 Annual MDS indicated the resident was severely cognitively impaired. Resident 10's 10/2023 Respiratory Care Plan revealed the following: -The resident required a long term tracheostomy to maintain airway and adequate oxygen levels. -Report any signs of respiratory distress, decreased saturations, fever, changes in mentation, increased vital signs and purulent (thick fluid caused by infection) tracheostomy secretions. -Check settings on air compressor- oxygen and temperature 80-85 degrees. -Check tubing and clear if water present. -Check tracheostomy strap (a band that goes around the neck to hold the tracheostomy tube in place)…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-18 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review it was determined the facility failed to ensure resident care plans were revised to accurately reflect resident needs for 1 of 1 sampled resident (#18) reviewed for skin conditions. This placed residents at risk for unmet care needs. Findings include: Resident 18 was admitted to the facility in 5/2017 with diagnoses including hemiplegia (muscle weakness or partial paralysis on one side of the body). On 12/11/23 at 3:34 PM Resident 18 was observed to have multiple red marks that appeared to be scabbed over on her/his right shoulder. Resident 18 stated she/he did not know what they were. On 12/13/23 at 3:01 PM Resident 18 was observed to have similar red marks and scabs on her/his leg. Resident 18 stated the sores were healing and she/he thought they were dry skin. She/he stated staff applied cream to them but she/he did not remember when. On 12/15/23 at 9:29 AM Staff 15 (LPN) stated Resident 18 had really dry skin and she/he picked at it. She confirmed Resident 18's skin sores were treated with calamine (a lotion used to treat mild…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-18 · 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

    2. Resident 4 was admitted to the facility in 2/2021 with diagnoses including multiple sclerosis (a progressive neurological disease). Resident 4's 2/2/22 Care Plan, revised 12/23/23, revealed the resident required extensive assistance for grooming and personal hygiene and preferred showers so she/he could have her/his hair shampooed. The staff were to brush Resident 4's hair daily. Resident 4's 9/27/23 Quarterly MDS revealed she/he had moderate cognitive impairment, required total assistance for bathing/showering, required extensive assistance for personal hygiene and had no rejection of care. Resident 4's 11/22/23 through 12/16/23 Shower Task Logs indicated the resident received bathing/showering on the following days: -12/2/23 and -12/9/23. A review of Resident 4's health record from 11/22/23 through 12/16/23 revealed no documentation that Resident 4 was provided with additional bathing/showering opportunities when bathing/showering was not provided. On 12/11/23 at 2:48 PM and 12/12/23 at 8:39 AM Resident 4 looked disheveled. The resident had an area at the crown of her/his head…

    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 · D2023-12-18 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 a person-centered activity program for 1 of 1 sampled resident (#21) reviewed for activities. This placed residents at risk for a diminished quality of life. Findings include: Resident 21 was admitted to the facility in 11/2023 with diagnoses including lower back fracture. Resident 21's 11/20/23 admission MDS indicated the resident's preferred language was Russian, the resident wanted an interpreter to communicate with health care staff and the resident did not experience any difficulties with communication. The MDS also indicated listening to music she/he liked and being around animals, such as pets, were important activities to Resident 21. Resident 21's 11/21/23 Activities Initial Assessment completed with the resident indicated she/he liked music, dogs, playing cards and board games and getting her/his nails done. Resident 21's 11/22/23 Activity Care Plan revealed the following interventions: -Provide 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 · D2023-12-18 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review it was determined the facility failed to ensure physician orders were implemented as ordered for 1 of 1 sampled resident (#437) reviewed for edema. This placed residents at risk for worsened edema and unmet needs. Findings include: Resident 437 was admitted to the facility in 12/2023 with diagnoses including fracture of the right femur (thigh bone) and Down syndrome. Resident 437's admission MDS was in progress and the resident's assessment information was not completed. A 12/7/23 Encounter Note written by Staff 25 (Physician) included the following: - Tubigrips [support bandage] until compression stockings can be put on. Also ACE wraps [stretchable cloth] if Tubigrips are not available. Resident 437's Physician Orders included a 12/7/23 order for ACE wraps to be used daily to lower legs during the day. Resident 437's 12/2023 TAR revealed the 12/7/23 order for ACE wraps was not implemented until 12/12/23, five days after the Physician Order. On 12/11/23 at 11:25 AM Witness 2 (Family) stated she visited Resident 437 every day since…

    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 · D2023-12-18 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    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 the provision of appropriate equipment at a resident's bedside in the case of a complication related to a laryngectomy (surgical removal of all or part of the larynx (voicebox)), a care plan was developed with appropriate interventions for respiratory care and physician orders for respiratory equipment were followed for 2 of 3 sampled residents (#s 74 and 435) reviewed for respiratory care. This placed residents at risk for respiratory distress and unmet needs. Findings include: 1. Resident 74 was admitted to the facility in 6/2023 with diagnoses including acquired absence of larynx. Resident 74's 8/2023 Laryngectomy Care Plan indicated the following: -Clean tube per order directions. -Monitor/document for restlessness, agitation, confusion, increased heart rate and bradycardia (slow heart rate). -Monitor/document level of consciousness, mental status and lethargy PRN. -Provide good oral care daily and PRN. -Suction…

    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 · D2023-12-18 · tag F0699 — isolated
    Provide 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

    Based on interview and record review it was determined the facility failed to ensure a resident who was a trauma survivor received trauma-informed care for 1 of 1 sampled resident (#21) reviewed for mood. This placed residents at risk for re-traumatization and a decrease in their quality of life. Findings include: The facility's 2019 Trauma-Informed Care Policy revealed the following: -Each resident would be screened for a history of trauma upon admission. -The facility would account for residents' experiences, preferences, and cultural differences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident and a care plan would be completed as appropriate. Care plan interventions would be reviewed and modified as appropriate. -If the resident was non-English speaking, the facility would identify how communication would occur with the resident. The facility would engage the services of an interpreter to monitor or evaluate the effect of cultural interventions for non-English speaking residents. -The facility would collaborate with resident trauma…

    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 · D2023-12-18 · tag F0761 — failed to label and store drugs safely — isolated
    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 medications and biologicals were secured and accessible only to authorized personnel for 1 of 1 facility observed for secure medication and treatment carts. This placed residents at risk for misappropriation of medications and adverse medication consequences. Findings include: The facility Medication Storage Policy and Procedure dated 11/12/15 stated: -During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. On 12/11/23 at 10:08 AM the treatment cart on the west hall was unlocked and unattended by staff. On 12/11/23 at 10:34 AM Staff 17 (LPN) confirmed the cart was left unlocked and unattended. On 12/15/23 at 11:06 AM the medication cart on the [NAME]/[NAME] hall was unlocked and unattended by staff. On 12/15/23 at 11:20 AM Staff 18 (RN) confirmed the cart was left unlocked and unattended. On 12/15/23 at 11:34 AM Staff 2 (DNS)…

    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 before2019-08-05 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, it was determined the facility failed to provide a clean and sanitary environment for 1 of 1 kitchen observed. This placed residents at risk of receiving contaminated food. Findings include: On 7/29/19 at 10:15 AM, during the initial tour of the kitchen with Staff 3 (Cook) the following kitchen observations were identified: - Build up of dust and debris on multiple ceiling vents and overhead pipes going throughout the kitchen including those directly above food preparation areas. - Build up of dust and grease on a metal shelf with bread items placed on it. - Build up of dust and grease on the back of the metal stove hood vent near a food preparation countertop. - The ceiling over a food preparation area was sagging, peeling, and had loose material hanging from it. - Dried on food debris and splatter located under the shelf directly above the steam table. On 7/29/19 at 4:10 PM and 7/31/19 at 3:38 PM, Staff 2 (RD/Dietary Manager) was shown and acknowledged the identified areas were in need of cleaning and repair.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-08-05 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review it was determined the facility failed to ensure adequate indication and clinical rationale for the use of an antipsychotic medication for 1 of 5 sampled residents (#67) whose medications were reviewed. This placed residents at risk for receiving unnecessary psychotropic medications and experiencing adverse side effects. Findings include: Resident 67 was admitted to the facility in 2/2019 with diagnoses including dementia with behavioral disturbance. Resident 67's 2/2019 TAR indicated Behavior Monitoring two times a day for the following: - behaviors for depression: anxiety, self-isolation, crying etc. - document number of occurrences of refusal of care. A 3/27/19 Care Visit Progress Note specified Resident 67 continued to refuse basic care including skin and peri-care, resulting in skin lesions; plan: Start Risperdal (an antipsychotic medication) 0.25 mg bid. Resident 67's signed Physician Orders included risperidone (generic form of Risperdal) 0.25 mg bid started on 3/28/19. Resident 67's 4/10/19 Psychotropic Medication Use CAA…

    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

$12,659 in federal fines across 1 penalty.

  • $12,659 — penalty dated 2023-12-18

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

Part of a chain

This home belongs to THE GOODMAN GROUP — 9 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 53.2+0.8 vs chain
Health inspection 3 of 52.8+0.2 vs chain
Staffing 4 of 53.7+0.3 vs chain
Quality measures 5 of 54.2+0.8 vs chain
The other 8 homes this chain runs (chain average 3.2★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
JOHN B. GOODMAN 2006 IRRV GRANTOR TROrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; 5% OR GREATER INDIRECT OWNERSHIP INTEREST; LIMITED PARTNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/28/2017
THE GOODMAN GROUP PROPERTIES LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; LIMITED PARTNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/01/2007
WERNER VENTURES LIMITED PARTNERSHIPOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; LIMITED PARTNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/01/1994
WEST HILLS CONVALESCENT CENTER LIMITED PARTNERSHIPOrganization5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 04/04/1990
BROWN, WENDYIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; LIMITED PARTNERSHIP INTEREST5%since 01/01/1994
WERNER, JEFFERYIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; LIMITED PARTNERSHIP INTEREST5%since 01/01/1994
GOULD, DENISEIndividualW-2 MANAGING EMPLOYEEsince 06/05/2023
WEICHERT, JAMESIndividualCORPORATE DIRECTORsince 10/01/2016
BENSON, RANDALLIndividualCORPORATE OFFICERsince 06/26/2016
EDINGER, CRAIGIndividualCORPORATE OFFICERsince 10/11/2016
KNACKE, CLINTONIndividualCORPORATE OFFICERsince 10/12/2022
OLSON, DENISEIndividualCORPORATE OFFICERsince 09/16/2013
JOHN B GOODMAN ENTERPRISES INCOrganizationGENERAL PARTNERSHIP INTERESTsince 04/04/1990

CMS files one row per role, so the 19 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted.

5 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.

$17.7M
Net patient revenuemost recent cost report
-3.8%
Operating marginrevenue minus expenses
$1.3M
Related-party expense7% of expenses
Who pays — share of resident-days
Medicaid 57%Medicare 12%Other / private 31%

This home reported $1.3M 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

$561per resident / day
operating cost
$17,048per month
≈ monthly operating cost
$540per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in OR

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Oregon Medicaid page.

Typical monthly cost in Oregon
$16,760/mo
Nursing home (semi-private)
$18,448/mo
Nursing home (private)
$6,875/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 385112. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-25, 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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