Salem Transitional Care
3445 Boone Road SE, Salem, OR 97317 · For profit - Corporation · 80 certified beds · (503) 576-3000 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has an abuse, neglect, or exploitation citation (F0600), cited Apr 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- 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 (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $22,523 in federal fines (most recent 2024-01-12)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- about 17% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 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
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Short-stay residents who newly got an antipsychotic medication | 0.7% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 79.9% | 81.2% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 23.4% | 21.4% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 13.5% | 16.1% | 12.0% | worse |
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.
74.0% 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 357 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 47.9% 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 194 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 1.10 therapist hours per resident per day in 2026Q1 — more than 97% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 74.0%CMS range 69.8–79.2 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 7.7%CMS range 5.9–10.4 | 10.7% | Oct 2022–Sep 2024 | better than U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 47.9% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 47.9% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 36.6% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | 98.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.3%CMS range 3.1–7.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.92 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 80 beds and averages 71.0 residents a day — about 89% occupied, or roughly 9 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.81 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.58 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.06 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 4.32 hrs/resident/day on weekends vs 5.00 on weekdays — 14% thinner on weekends. RN hours go from 0.72 to 0.24 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 45% 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
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
30 citations, most serious first. The 12 most serious are shown; the remaining 18 are one tap away and print in full.
- Actual harm · Gcited before2025-04-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review it was determined the facility failed to ensure a heat pack was safely applied for 1 of 1 sampled resident (#76) reviewed for accidents. Resident 76 sustained burns. Findings include: On 11/23/24 the Past Noncompliance was corrected when the facility initiated an investigation, identified the root cause of the incident, and provided CNA and nurse in-service training on the use of heat packs. The training included: 1. A nurse was to approve a heat pack prior to use for each resident, 2. A barrier was to be applied between the heat source and the resident's skin, and 3. A heat pack was only to be left on for a maximum of 20 minutes. Resident 76 was admitted to the facility in 10/2024 with a diagnosis of kidney disease. Resident 76's 11/3/24 admission MDS revealed she/he was cognitively intact, required partial assistance with upper body dressing, and did not have skin impairment. Resident 76's 11/2024 TAR did not have interventions for a heat pack. Resident 76's Progress Notes revealed the following: -11/23/24: Resident 76 was provided a heat pack…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2024-02-16 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to accurately assess, monitor, and prevent worsening of pressure ulcers for 1 of 3 residents (#1) reviewed for pressure ulcers. This failure resulted in the resident developing bilateral (both sides) Stage 4 pressure ulcers to the buttocks which required hospitalization, surgical intervention and placed other residents at risk for worsening pressure ulcers. Findings include: The National Pressure Ulcer Advisory Panel defined the following pressure injury stages: Stage 2 pressure ulcers: partial-thickness skin loss with exposed dermis presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-29 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to provide transfer assistance for 1 of 3 sampled residents (# 4) reviewed for ADL assistance. This placed residents at risk for unmet care needs.Resident 4 was admitted to the facility in 10/2025 with diagnoses of sepsis (unspecified organism), lobar pneumonia, and acute respiratory failure with hypoxia. A Nursing Care Note dated 10/31/25 documented Resident 4 was assisted back to her/his room after dinner. The assisting staff left the resident alone in her/his wheelchair in the room while obtaining assistance for a two-person transfer. Staff did not return to the resident's room for over one hour. Resident 4's MDS admission assessment dated [DATE] indicated the resident had a BIMS score of 14, was cognitively intact and was dependent for wheelchair mobility. A Risk Management Report dated 10/31/25, completed by Staff 12 (LPN), confirmed Resident 4 was left alone in her/his wheelchair in the room for over an hour while awaiting transfer…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-29 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to ensure physician orders were followed for 1 of 7 sampled residents (# 2) reviewed for physician orders. This placed residents at risk for medical complications and unmet medication needs. Findings include: Resident 2 was admitted to the facility in 7/2025 with a diagnosis of fracture right lower leg. Resident 2's admission MDS dated [DATE] revealed the resident had a BIMS score of 13 and was cognitively intact. The facility's Risk Management report dated 8/3/25 and a Progress Note dated 8/3/25 identified the facility failed to follow a physician's STAT order placed on 8/1/25 for Lokelma (a medication used to treat high blood potassium levels) for Resident 2. The on-call provider was notified of the missed medication and instructed nursing staff to send the resident to the emergency room. Resident 2 was sent to the emergency room on 8/3/25. On 1/26/25 at 2:59 PM, Witness 2 (Hospital Social Worker) stated the facility failed to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-04-15 · tag F0730 — patternObserve each nurse aide's job performance and give regular training.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, it was determined the facility failed to ensure annual performance reviews for CNA staff were completed for 5 of 5 sampled CNA staff (#s 3, 4, 5, 6, and 7) reviewed for staffing. This placed residents at risk due to lack of competent staff. Findings include: A review of personnel profile records revealed the following. -Staff 3 (hired on 2/19/15): performance review dated 3/20/20. -Staff 4 (hired on 1/13/15): performance review dated 2/2/18. -Staff 5 (hired on 3/23/15): performance review dated 3/11/21. -Staff 6 (hired on 12/5/18): performance review dated 3/25/20. -Staff 7 (hired on 2/19/20): No performance review provided. In a 4/15/25 interview at 7:18 AM with Staff 1 (Administrator), Staff 2 (DNS), and Staff 22 (Administrator in Training), Staff 2 stated she expected annual performance reviews to be completed in a timely manner.
- Potential for harm · E2025-04-15 · tag F0947 — failed to train nurse aides adequately — patternEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
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 have a system to ensure CNA staff received 12 hours of in-service training annually for 4 of 5 randomly selected staff members (#s 4, 5, 6, and 7) reviewed for in-service training. This placed residents at risk for care provided by incompetent staff. Findings include: A review of the facility's staff training records revealed the following: -Staff 4 (CNA), hired 1/13/15, had 1.5 hours of documented training (1/13/24-1/13/25). -Staff 5 (CNA), hired 3/23/15, had 2.25 hours of documented training (3/23/24-3/23/25). -Staff 6 (CNA), hired 12/5/18, had no documented training hours (12/5/23-12/5/24). -Staff 7 (CNA), hired 2/19/20, had 8.62 hours of documented training (2/19/24-2/19/25). In a 4/15/25 interview at 7:18 AM with Staff 1 (Administrator), Staff 2 (DNS), and Staff 22 (Administrator in Training), Staff 2 stated CNA staff were expected to complete the required 12 hours of training annually.
- Potential for harm · D2025-04-15 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to honor resident preference for medication administration for 1 of 1 resident (#77) reviewed for choices. This placed residents at risk for not having the opportunity to exercise her/his autonomy (self-governance) regarding choices. Findings include: Resident 77 was admitted to the facility in 9/2024 with diagnoses including stroke. A FRI (Facility Reported Incident) was received on 9/20/24. It alleged Resident 77 was administered her/his medications with a spoon, all at one time, by Staff 30 (Former CNA). Resident 77 was to receive her/his medication one pill at a time with water or applesauce. Resident 77 and Witness 7 (Friend) told Staff 30 to stop administering the medications multiple times, but she did not stop. Witness 7 went to the nurses station and found a nurse to stop Staff 30 from administering Resident 77's medications. Resident 77 and Witness 7 told Staff 14 (LPN) the resident took her/his medications one at a time with water or applesauce per her/his choice. A 9/20/24 Nursing Care Note added to special…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-15 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, it was determined the facility failed to honor resident choice for 1 of 1 sampled resident (#77) reviewed for medication administration. This placed residents at risk for choking. Findings include: Resident 77 was admitted to the facility in 9/2024 with diagnoses including brain cancer and stroke. A 9/20/24 FRI was received on 9/20/24 which alleged Staff 30 (Former CNA) administered medication to Resident 77. The 4/2019 facility policy, Administering Medications indicated: -Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. -The 10/2024 Scope of Practice Nurses vs CNAs indicated when medications are left in the resident's room, (usually not allowed) notify the nurse; do not administer or assist. The FRI indicated Staff 29 (CMA) entered Resident 77's room with her/his morning medications and realized Staff 30 was providing personal care for Resident 77. Staff 29 placed the resident's medication on the bedside table and left the resident's room. Staff 30 attempted to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-15 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review it was determined the facility failed to notify office of the State long-term care ombudsman of the transfer/discharge for 2 of 2 sampled residents (#s 26 and 52) reviewed for hospitalization. This placed residents at risk for lack of notification of their transfer/discharge. Findings include: Resident 26 admitted to the facility in 2/2025 with diagnoses including acute kidney failure and sepsis. A 3/15/25 progress note indicated Resident 26 was sent to the hospital on 3/17/25 for shortness of breath. A review of the resident's clinical record revealed no evidence the Long-term care ombudsman's office was notified of the resident's transfer/discharge. On 3/18/25 at 12:33 PM Staff 2 (DNS) acknowledged the ombudsman was not notified of Resident 26's discharge to the hospital. 2. Resident 52 was admitted to the facility in 3/2024 with a diagnosis of Parkinson's disease. Resident 52's Progress Notes revealed on 3/18/25 she/he was discharged to the hospital. Resident 52's clinical record did not indicate the State's LTCO's (Long Term Care Ombudsman)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-15 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review it was determined the facility failed to provide a resident representative a bed hold policy for 1 of 2 sampled residents (#52) reviewed for hospitalization. This placed residents at risk for lack of knowledge related to their right to return to the facility. Findings include: Resident 52 was admitted to the facility in 3/2024 with a diagnosis of Parkinson's disease. Resident 52's 3/11/25 admission MDS revealed she/he was cognitively impaired. Resident 52's Progress Notes revealed she/he was discharged to the hospital on 3/18/25. Resident 52's clinical record did not indicate Witness 6 (Spouse) was notified of the facility's bed hold policy. On 4/7/25 at 3:28 PM Witness 6 stated on 3/18/25, when Resident 52 was hospitalized , she/he was not notified of the bed hold policy. On 4/10/25 at 10:27 AM Staff 23 (Admissions) stated she provided the bed-hold policy to residents and/or their representative upon admission to the facility and when residents were hospitalized . If a resident was hospitalized she called the resident or representative and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-15 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
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 staff failed to follow professional standards of practice for medication administration for 1 of 1 sampled resident (# 77) reviewed for medication administration.This placed residents at risk for unsafe medication administration. Findings include: Resident 77 was admitted to the facility in 9/2024 with diagnoses including brain cancer and stroke. On 9/20/24, a FRI was received on 9/20/24 which alleged Staff 30 (Former CNA) administered medication to Resident 77. The 4/2019 facility policy; Administering Medications indicated: -Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. -The 10/2024 Scope of Practice Nurses vs CNAs indicated when medications are left in the resident's room, (usually not allowed) notify the nurse; do not administer or assist. The FRI indicated Staff 29 (CMA) entered Resident 77's room with morning medications and found Staff 30 was providing personal care for Resident 77. Staff 29 left the resident's medication on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-15 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined the facility failed to ensure residents' pressure injuries were monitored and care plans were updated for 2 of 3 sampled residents (#s 52 and 77) reviewed for pressure ulcers and choices. This placed residents at risk for worsening pressure injuries. Findings include: 1. Resident 52 was readmitted to the facility on [DATE] with a diagnosis of blood loss anemia. Resident 52's care plan for skin impairment initiated 3/7/25 and last revised on 3/10/25 revealed she/he was at risk for pressure ulcers due to weakness. Interventions included weekly skin assessments and new skin impairments were to be reported to the nurse. Resident 52's 3/18/25 admission MDS revealed Resident 52 was admitted to the facility with no pressure ulcers but had maroon discoloration to her/his great toes. Staff were to monitor her/his skin weekly. Resident 52's 3/30/25 admission Nursing Database revealed Resident 52 did not have skin impairment. Resident 52's Progress Notes…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 18 citations
- Potential for harm · D2025-04-15 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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 adequate catheter care for 1 of 2 sampled residents (#226) reviewed for catheter care. This placed residents at risk for unmet catheter needs. The facility's External Catheter Policy, dated 2001, revealed: To verify a physician's order existed for the procedure, review the resident's care plan to assess any special needs, and assemble the equipment and supplies. Resident 226 was admitted to the facility in 4/2025 with a diagnosis including kidney failure. A 4/3/25 Hospital History and Physical Notes indicated Resident 226 had an external urinary catheter placed on 3/31/25. A 4/6/24 SBAR (Situation, Background, Assessment, and Recommendation) Note indicated Resident 226 continued to void dark urine, denied any urinary issue, and her/his catheter was changed. Resident 226's care plan lacked documentation of a catheter, and no physician-ordered treatment for a catheter was found on the TAR. On 4/10/25 at 1:05 PM, Resident 226 stated her/his catheter was removed on 4/9/25. On 4/11/25 at 10:59 AM,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-15 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
2. Resident 62 was admitted to the facility in 3/2025 with diagnoses including hypertension (high blood pressure) and heart disease. The 3/2025 and 4/2025 MARs directed one time a day administration of isosorbide mononitrate (prevents chest pain and dilates blood vessels) for hypertension. Resident 62 received five doses from 3/19/25 through 3/23/25, five doses from 3/27/25 through 3/31/25, and four doses from 4/1/25 through 4/4/25. On 4/5/25, the MAR referred to electronic medication administration record (eMAR) notes. The MAR indicated medication administration on 4/6/25 and 4/7/25, but on 4/8/25, it referred to the eMAR notes. A 4/5/25 eMAR Order Note directed the administration of isosorbide mononitrate once daily and noted the medication card was not available within the facility. A 4/8/25 eMAR Order Note directed the administration of isosorbide mononitrate once daily and noted the medication was unavailable; the pharmacy was contacted, and the facility awaited delivery. On 4/11/25 at 9:10 AM, Staff 10 (CMA) confirmed on 4/5/25 she was unable to locate the isosorbide…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-15 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure 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 a resident was administered ibuprofen (NSAIDS/nonsteroidal anti-inflammatory drug) as prescribed for 1 of 2 sampled residents (#52) reviewed for hospitalization. This contributed to Resident 52's intestinal bleed and hospitalization. Findings include: Resident 52 was admitted to the facility in 3/2025 with a diagnosis of obesity. Resident 52's Progress Notes revealed on 3/14/25 staff communicated with Resident 52's physician, reported her/his family was at the facility, and family was concerned about Resident 52's increased tremors and shaking. Staff indicated Resident 52 reported she/he was cold, but did not have a fever, or other signs and symptoms of infection. Per epocrates.com (online pharmacy resource: ibuprofen Black Box Warnings (content published with prescribing information if the Food and Drug Administration released proposed language for a new or updated boxed warning) indicated NSAIDs increase risk of serious and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-17 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review it was determined the facility failed to ensure residents were treated with dignity for 1 of 2 sampled residents (#1) reviewed for dignity and abuse. This placed residents at risk for lessened quality of life. Findings include: The facility's Dignity Policy, last revised 2/2021, indicated staff were to treat all residents with dignity and speak respectfully. Resident 1 was admitted to the facility in 6/2024 with diagnoses including dementia and a stroke with speech deficit. A 6/25/24 admission MDS indicated Resident 1 was unable to participate in cognitive testing due to a speech deficit but did understand yes and no questions. An 8/10/24 revised care plan revealed Resident 1 had known behaviors of fidgeting, anger, frustration, and yelling. The care plan included triggers and interventions. A review of a 8/12/24 facility investigation regarding alleged lack of dignity and respect indicated Staff 3 (LPN) willfully intimidated Resident 1. Staff 3 was terminated from employment. On 10/14/24 at 12:39 PM Staff 4 (CNA) stated Resident 1 had behaviors…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-17 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
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 Staff 3 (LPN) adhered to professional standards of practice regarding residents' dignity and plan of care for 1 of 2 sampled residents (#1) reviewed for abuse and dignity. This placed residents at risk for abuse and undignified treatment. Findings include: The Oregon State Board of Nursing Conduct Derogatory to the Standards of Nursing (OAR [PHONE NUMBER]) outlined nurses, regardless of role, whose behavior fails to conform to the legal standard and accepted standards of the nursing profession, or who may adversely affect the health, safety, and welfare of the public, may be found guilty of conduct derogatory to the standards of nursing. Such conduct shall include, but is not limited to, the following: -Failing to respect the dignity and rights of residents; - Failing to develop, implement and/or follow through with the plan of care; Resident 1 was admitted to the facility in 6/2024 with diagnoses including dementia and a stroke…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-17 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
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 allegation of verbal abuse was reported to the SSA (State Survey Agency) within the required reporting time of two hours for 1 of 3 sampled residents (#4) reviewed for verbal abuse. This placed residents at risk for potential ongoing abuse. Findings include: Resident 4 was admitted to the facility in 1/2024, with diagnoses including bilateral leg fractures and chronic pain. Resident 4's 1/17/24 admission MDS revealed she/he was cognitively intact and had no behaviors. A Grievance Community Form dated 1/18/24, indicated Resident 4 reported to Staff 4 (LPN/RCM) an incident involving Witness 1 (Agency Nurse). Resident 4 reported Witness 1 was rude and disrespectful during a dressing change and failed to use caution when moving her/his fractured leg. Staff 4 indicated she assisted Resident 4 with completing the Grievance Community Form and contacted Witness 1 and did not receive a call back. A Grievance Community Form dated 1/22/24, revealed Resident 4 and her/his family requested to talk with Staff 4…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-17 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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 thoroughly investigate an allegation of verbal abuse for 1 of 3 sampled residents (#4) reviewed for verbal abuse. This placed residents at risk for potential ongoing abuse. Findings include: Resident 4 was admitted to the facility in 1/2024, with diagnoses including bilateral leg fractures and chronic pain. Resident 4's 1/17/24 admission MDS revealed she/he was cognitively intact and had no behaviors. Resident 4's medical record indicated facility Grievance Community Forms were completed on 1/18/24 and 1/22/24 related to an allegation of verbal abuse by Witness 1 (Agency Nurse). Resident 4 reported Witness 1 was rude and disrespectful and failed to use caution when moving her/his leg during a dressing change. On 2/13/24 the SSA (State Survey Agency) received a FRI for the facility's 1/18/24 incident reported by Resident 4, which was 18 days after the allegation of verbal abuse occurred. The FRI indicated an investigation was ongoing at this time. The facility's 1/22/24 Incident Report included three…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-01-12 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review it was determined the facility failed to ensure appropriate medication storage temperatures were logged and maintained, and failed to ensure proper labeling of biologicals for 2 of 2 medication storage refrigerators reviewed for safe medication storage. This placed residents at risk for receiving medications with reduced efficacy. Findings include: 1. On 1/12/24 at 11:52 AM the medication refrigerator on the 200 hall was observed with Staff 9 (CMA). The thermometer inside of the refrigerator indicated it was at 24 degrees F. Staff 9 confirmed the thermometer read 24 degrees F. The 1/2024 temperature log indicated to keep the refrigerator between 36 degrees F and 46 degrees F. On 1/12/24 at 12:35 PM the medication refrigerator on the 200 hall was observed with Staff 2 (DNS). The thermometer inside of the refrigerator indicated it was 34 degrees F. On 1/12/24 at 12:35 PM Staff 2 acknowledged the refrigerator temperature should be between 36 degrees F and 46 degrees F. Staff 2 further acknowledged the refrigerator contained emergency…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-12 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review it was determined the facility failed to develop a comprehensive care plan to address hearing loss and the use of hearing aids for 1 of 1 sampled resident (#8) reviewed for hearing. This placed residents at risk for decreased ability to communicate. Findings include: Resident 8 admitted to the facility in 11/2023 with diagnoses including hearing loss. A 11/13/23 admission Nursing Assessment indicated Resident 8 was hard of hearing in both ears, used hearing aids, and had moderate difficulty hearing when not using the aids. A review of Resident 8's care plan on 1/11/24 revealed no information regarding the resident's impaired hearing or use of hearing aids. On 1/10/24 at 11:32 AM and 1/11/24 at 9:24 AM Resident 8 was observed to have difficulty hearing and the resident was not wearing hearing aids. Resident 8 stated she/he did not wear the hearing aids because they were broken. During interviews from 1/11/24 through 1/12/24 with Staff 9 (CMA), Staff 11 (CNA), and Staff 12 (LPN) the staff indicated Resident 8 was hard of hearing. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-12 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review it was determined the facility failed to ensure staff adhered to professional standards related to the administration of pain medication. This placed residents at risk for experiencing pain. Findings include: Resident 221 admitted to the facility in 8/2023 with diagnoses including femur fracture. An 8/19/23 physician order indicated Resident 221 was to receive oxycontin (opioid pain medication) every 12 hours for pain at 9:00 AM and 9:00 PM. The 9/2023 MARs indicated the following: -Resident 221's oxycontin was to be administered at 9:00 PM. -On 9/9/23 at 9:00 PM the MAR was blank. -No documentation was found to indicate the reason the MAR was left blank on 9/9/23. The 9/11/23 facility investigation indicated the following: -On 9/10/23 Resident 221 told Staff 4 (LPN) she/he did not receive pain medication on the evening of 9/9/23. Resident 221 stated she/he asked for pain medication on 9/9/23 between 9:00 PM and 10:00 PM. Two hours later she/he requested pain medication again. Resident 221 stated Staff 3 (Agency RN) came into her/his room and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-12 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review it was determined the facility failed to assist with a hearing device for 1 of 1 sampled resident (#8) reviewed for hearing. This placed residents at risk for social isolation and decreased quality of life. Findings include: Resident 8 admitted to the facility in 11/2023 with diagnoses including hearing loss. A 11/13/23 admission Nursing Assessment indicated Resident 8 was hard of hearing in both ears, used hearing aids, and had moderate difficulty hearing when not using the aids. The 11/19/23 admission MDS indicated Resident 8 had adequate hearing and did not use hearing aids. A review of Resident 8's care plan on 1/11/24 revealed no information regarding the resident's impaired hearing or use of hearing aids. On 1/10/24 at 11:32 AM and 1/11/24 at 9:24 AM Resident 8 was observed to have difficulty hearing and the resident was not wearing hearing aids. When interviewed on 1/10/24 at 11:32 AM Resident 8 stated she/he did not wear the hearing aids because they were broken. On 1/11/24 at 11:15 AM Staff 11 (CNA) indicated Resident 8 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined the facility failed to implement care planned interventions for falls for 1 of 3 sampled residents (#21) reviewed for falls. This placed residents at risk for injury from falls. Findings include: Resident 21 admitted to the facility in 12/2023 with diagnoses including repeated falls. The resident's care plan for falls, initiated on 12/2/23, indicated Resident 21's bed was to be kept low except during care. A 12/7/23 incident report indicated Resident 21 experienced a fall with no injuries. The 12/8/23 admission MDS indicated Resident 21 had a history of falls including one since admission to the facility. A 12/9/23 incident report indicated Resident 21 experienced a fall with no injuries. A 12/25/23 incident report indicated Resident 21 experienced a fall with injury. The resident's [NAME] (condensed care plan for quick reference by staff) was reviewed on 1/11/24 and indicated Resident 21's bed was to be kept in the lowest position except…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-12 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
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 received pain medication as ordered for 1 of 3 sampled residents (#221) reviewed for pain. This placed residents at risk for increased pain. Findings include: Resident 221 admitted to the facility in 8/2023 with diagnoses including femur fracture. An 8/19/23 physician order indicated Resident 221 was to receive oxycontin (opioid pain medication) every 12 hours for pain at 9:00 AM and 9:00 PM. The 9/2023 MARs indicated the following: -Resident 221's oxycontin was to be administered at 9:00 PM. -On 9/9/23 at 9:00 PM the MAR was blank. -No documentation was found to indicate the reason the MAR was left blank on 9/9/23. A 9/11/23 facility investigation indicated Staff 3 (Agency RN) worked the night shift on 9/9/23 and did not administer Resident 221's oxycontin at 9:00 PM as ordered due to a technical reason. Staff 4 (LPN) administered pain medications to Resident 221 on day shift after the resident reported she/he did not receive scheduled oxycontin on 9/9/23 at 9:00 PM. Resident 221 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.
- Potential for harm · D2023-09-12 · tag F0825 — isolatedProvide or get specialized rehabilitative services as required for a resident.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to provide rehabilitation services for 1 of 3 sampled residents (#2) reviewed for rehabilitation services. This placed residents at risk for declined mobility and lack of quality of life. Findings include: Resident 2 admitted to the facility on [DATE] and discharged on 1/10/23 with diagnoses including muscle weakness. On 1/25/23 a concern was reported to the State Agency indicating Resident 2's therapy sessions were sometimes canceled and the resident received two physical therapy sessions in 10 days. Review of the 12/22/22 Physical Therapy Plan of Treatment indicated Resident 2 was to receive daily therapy services five times a week. Review of the therapy Service Log Matrix from 12/22/22 through 1/10/23 indicated Resident 2 missed 12 physical therapy sessions. On 9/11/23 at 10:45 AM Staff 4 (Therapy Director) acknowledged Resident 2 did not receive physical therapy on the identified dates.
- Potential for harm · E2022-11-04 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — the official record, unedited, 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 staff completed appropriate hand hygiene for 2 of 6 halls ([NAME] Hills and [NAME] Creek) reviewed for infection control. This placed residents at risk for infections. Findings include: On 11/2/22 at 12:17 PM Staff 21 (CNA) delivered meals on [NAME] Hills hall, she delivered and set up meal trays in rooms 212, 215 and 219 without completing hand hygiene before and between each room. On 11/2/22 at 12:20 PM Staff 21 stated she did not completed hand hygiene but should have between each room when she delivered meals. On 11/3/22 at 12:12 PM Staff 5 (CNA) delivered meal trays on [NAME] Creek Hall, she delivered and set up the meal tray in room [ROOM NUMBER] and then went down the hall to two additional rooms without completing hand hygiene between each room. On 11/4/22 at 10:22 AM Staff 2 (DNS) stated staff were to complete hand hygiene between each resident room when delivering meal trays.
- Potential for harm · Dcited before2022-11-04 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to develop a comprehensive care plan for seizure diagnosis and anticoagulation (blood thinner) treatment for 1 of 5 sampled residents (#4) reviewed for unnecessary medications. This placed residents at risk for unmet medical needs. Findings include: Resident 4 was admitted to the facility in 10/2022 with diagnoses of atrial fibrillation (irregular heartbeat) and seizures. A 10/11/22 physician orders revealed Resident 4 took antiseizure medications (divalproex sodium and phenobarbital) for convulsions (irregular body movements) and a blood thinner (warfarin) for atrial fibrillation. The 10/11/22 Care Plan and the 10/11/22 [NAME] revealed staff were not directed to monitor for side effects related to use of blood thinner or for seizure activity. Resident 4's 10/2022 TAR did not include monitoring for blood thinner side effects or seizure activity. On 11/3/22 at 12:40 PM Resident 4 stated she/he took blood thinners since 2003 and she/he took…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-11-04 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to revise a care plan to reflect resident seizure-like activity for 1 of 3 sampled residents (#23) reviewed for accidents. This placed residents at risk for unmet care needs. Finding include: Resident 23 was admitted to the facility in 2022 with diagnoses including Parkinson's Disease (a progressive disease of the nervous system) and weakness. A Progress Note dated 10/13/22 indicated Resident 23 was sent to the hospital emergency department on 10/13/22 for altered mental status and a possible seizure. Resident 23 returned to the facility on [DATE] with a diagnosis of transient alteration of awareness (a brief episode of losing normal awareness). A Progress Note dated 10/17/22 indicated Resident 23 was sent to the hospital emergency department on 10/17/22 for convulsions (involuntary contraction of muscles). Resident 23 returned to the facility on [DATE] with diagnoses of UTI and seizure-like activity. A Progress Note dated 10/20/22…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-11-04 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
1. Based on interview and record review it was determined the facility failed to provide appropriate treatment to a non-pressure wound for 1 of 2 sampled residents (#4) reviewed for non-pressure wound care. This resulted in an infection and deterioration of a non-pressure wound on Resident 4's left shin. This placed residents at risk for worsening wounds and infections. Findings include: The facility's undated Negative Pressure Wound Therapy (wound method that uses vacuum assisted closure (Wound V.A.C.) to draw out fluid and infection from a wound to help it heal) Dressing Change procedure indicated to window pane around the edges of the wound with transparent drape (place a clear dressing on the skin around the wound). Resident 4 admitted to the facility in 10/2022 with a non-pressure wound to her/his left shin. Resident 4's 10/11/22 physician order revealed the following: Wound V.A.C. to left shin wound: cleanse wound with normal saline, apply no sting barrier film and window pane around wound; apply foam to wound bed, cover with film drape and place suction. The 10/2022 TAR…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$22,523 in federal fines across 1 penalty.
- $22,523 — penalty dated 2024-01-12
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 CASCADIA HEALTHCARE — 46 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 3.0 | -1.0 vs chain |
| Health inspection | 2 of 5 | 2.8 | -0.8 vs chain |
| Staffing | 3 of 5 | 2.7 | +0.3 vs chain |
| Quality measures | 4 of 5 | 3.9 | +0.1 vs chain |
The other 45 homes this chain runs (chain average 3.0★, per CMS)
Showing 40 of 45; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| CASCADIA OREGON OPERATIONS LLC | Organization | DIRECT OWNERSHIP INTEREST | since 12/01/2025 |
| CASCADIA HC GROUP LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 12/01/2025 |
| CASCADIA HEALTHCARE LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 12/01/2025 |
| CASCADIA HOLDCO LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 12/01/2025 |
| LAFORTE, STEPHEN | Individual | INDIRECT OWNERSHIP INTEREST | since 12/01/2025 |
| WHITE OAK HEALTHCARE FINANCE LLC | Organization | 5% OR GREATER SECURITY INTEREST | since 12/01/2025 |
| HAMMOND, OWEN | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 12/01/2025 |
| CASCADIA SERVICES LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/06/2025 |
| HARBERT, SHAWN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/23/2026 |
| JAMES, PATRICK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/21/2025 |
| RUDEN, NATHAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/21/2025 |
| SALEM 3445 REALTY, LLC | Organization | ADP OF THE SNF | since 12/01/2025 |
CMS files one row per role, so the 17 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
7 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.
This home reported $2.4M paid to related parties — landlords or management companies under common ownership — equal to about 17% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OR
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Oregon Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 385234. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-15, 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.