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Columbia Basin Care Facility

1015 Webber Street, The Dalles, OR 97058 · Government - City/county · 90 certified beds · (541) 296-2156 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Aug 2024Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation$52,030 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Aug 2024
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (35) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $52,030 in federal fines (most recent 2026-02-02)
  • its independent health-inspection rating is low (1/5)
  • its payroll-based staffing rating is low (1/5)
  • its facility-reported quality-measure rating is low (2/5)
  • nursing-staff turnover (68%) runs well above the national median (45%)

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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1040 Webber St · (541) 296-4610 · Call to confirm hours
Pharmacy
Walgreens0.7 mi
515 Mount Hood St · (541) 296-3190 · Call to confirm hours
Grocery
1300 W 6th St · (541) 506-5055 · Call to confirm hours
Park
602 W 2nd St · (541) 296-9533 · 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 2 of 5
Long-stay residentspeople who live here 1 of 5
Short-stay residentsrehab / post-hospital 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 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 rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased25.2%14.9%15.4%worse
Long-stay residents who lose too much weight12.6%4.7%5.4%worse
Long-stay residents with a catheter left in their bladder6.0%1.4%0.9%worse
Long-stay residents with a urinary tract infection2.2%2.0%2.0%worse
Long-stay residents with depressive symptoms0.8%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 injury5.1%2.4%3.3%worse
Long-stay residents whose ability to walk worsened28.1%20.6%16.1%worse
Long-stay residents on antianxiety or hypnotic medication8.5%12.4%18.9%better
Long-stay residents given the seasonal flu vaccine97.3%95.2%95.3%typical
Long-stay residents with pressure ulcers4.8%5.8%4.7%typical
Long-stay residents with worsening bladder/bowel control25.0%21.8%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table31.0%13.9%17.1%worse
Short-stay residents who newly got an antipsychotic medication4.6%1.4%1.4%worse
Short-stay residents given the seasonal flu vaccine81.5%81.2%79.4%typical
Short-stay residents rehospitalized after admission15.8%21.4%22.6%better
Short-stay residents with an outpatient ER visit21.5%16.1%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.231.481.67better
Long-stay outpatient ER visits per 1,000 resident days2.112.351.80worse

§ 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.

61.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 113 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

61.4%U.S. median 51.5%
Got home and stayed home
10.4%U.S. median 10.7%
Went back to hospital
52.9%U.S. median 56.6%
Met the expected recovery
0.18U.S. median 0.31
Therapy hours / resident / day
0.08hours / resident / day
Physical therapy
0.06hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 52.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 68 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.18 therapist hours per resident per day in 2026Q1 — more than 18% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 14% 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 SNF61.4%CMS range 53.4–68.751.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.4%CMS range 7.1–14.210.7%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 discharge52.9%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge48.5%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 discharge45.6%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 identified82.8%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 setting95.9%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 discharge82.6%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.1%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 worsened3.5%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.5%CMS range 4.0–11.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.681.02Oct 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

0.77
RN hours/ resident / day
0.45
LPN hours/ resident / day
2.92
Aide hours/ resident / day
4.13
Total nurse hours/ resident / day
0.42
RN hoursweekends
68.2%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 90 beds and averages 41.3 residents a day — about 46% occupied, or roughly 49 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 4.13 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.77 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.92 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 3.59 hrs/resident/day on weekends vs 4.35 on weekdays — 18% thinner on weekends. RN hours go from 0.91 to 0.42 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 68% is well above 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

8
deficiencies at the latest standard inspection (2026-02-02)
15
at the previous standard inspection (2024-08-30)

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.

35 citations, most serious first. The 13 most serious are shown; the remaining 22 are one tap away and print in full.

  • Immediate jeopardy · Kcited before2026-02-02 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to properly disinfect glucose monitors with approved disinfectant wipes between resident uses for 3 of 3 halls reviewed for CBG monitoring. This failure placed residents at risk for blood borne infection. The deficient practice was determined to be an Immediate Jeopardy (IJ) situation. Resident 1 had an active diagnosis of Hepatitis C, and received CBG checks from a community use glucometer, which was not properly sanitized before use with other residents. Findings include:The facility's 10/2011 Obtaining a Fingerstick Glucose Level Policy indicated, Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice.A 9/2024 Arkray Technical Brief Manufacturer Manual indicated, Disinfect common use glucometers with the use of approved disinfectant wipes. The glucometer was to be wiped with the disinfecting wipe and left wet for two minutes 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2026-02-02 · tag F0691 — failed to provide colostomy / ostomy care — isolated
    Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to provide necessary care and services for ileostomy (surgical opening in the abdominal wall that provides a way for the end of the small intestine to release stool) care for 1 of 1 sampled resident (#13) reviewed for bladder and bowel incontinence. This failure resulted in the Resident 13 experiencing excoriation (a skin injury involving the removal of skin), increased pain and discomfort, unmet ileostomy care needs, a delay in medical care and psychosocial harm. Findings include: The facility's 1/1/26 Ostomy (an artificial opening in an organ of the body, created during an operation) Care Policy instructed the following: -Ostomy care will be provided by licensed nurses under the orders of the attending physician.-The resident's goals and preferences for care and treatment of the ostomy will be used to formulate a plan of care for the ostomy. -The frequency of pouch changes and the products required for changing ostomy…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2023-05-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review it was determined the facility failed to ensure residents did not experience an injury during a transfer for 2 of 4 sampled residents (#s 14 and 160) reviewed for accidents. This failure resulted in major injury and hospitalization. Findings include: 1. Resident 14 was admitted to the facility in 4/2015 with diagnoses including Alzheimer's disease. Resident 14's 4/11/17 Care Plan indicated the resident required a mechanical lift transfer with two staff. Resident 14's 11/23/20 Quarterly MDS indicated the resident was severely cognitively impaired, her/his arms were impaired and she/he was totally dependent on two people for transfers. A 12/21/20 Progress Note written by Staff 26 (Former Staff RN) revealed at 6:25 AM, Resident 14 fell from the mechanical lift sling while being transferred from her/his bed to the wheelchair. Resident 14 fell backwards and head first to the ground. Staff 26 assessed Resident 14 and noted the back of the resident's head had a 8 cm x 7 cm hematoma (mass of blood and bruising), a 4 cm x 0.8 cm laceration…

    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 · E2026-02-02 · tag F0847 — pattern
    Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to ensure residents were fully informed and understood the binding arbitration agreement for 3 of 3 sampled residents (#s 1, 2 and 45) reviewed for binding arbitration agreement. This placed residents at risk of being uninformed regarding their legal rights. Findings include:The facility's 1/1/26 Binding Arbitration Agreements Policy indicated the facility shall do the following when explaining the arbitration agreement:-Explicitly inform the resident or his or her representative of his or her right not to sign the agreement as a condition of admission to, or as a requirement to continue to receive care at this facility.-Explain to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands. -Ensure the resident or his or her representative acknowledges that he or she understands the agreement. The facility's undated Arbitration Agreement included the following:-You acknowledge that you have the option of not signing…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-02 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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 the facility failed to timely report an allegation of physical abuse for 1 of 2 sampled residents (#24) reviewed for abuse. This placed residents at risk for potential abuse. Findings include:The facility's 1/1/26 Abuse and Neglect Protections and Responsibilities Policy directed the Executive Director (Administrator) or designee to immediately report all allegations of suspected abuse through a FRI. During the 1/26/26 at 9:26 AM entrance conference meeting, Staff 1 (Administrator) notified the surveyor the facility had an incident over the weekend and were going to submit a FRI to the SA (state agency).On 1/26/26 at 12:14 PM Staff 2 (DNS) notified the surveyor Resident 24 was involved in an allegation of abuse on 1/24/26 and the facility would complete a FRI when the investigation was complete.On 1/29/26 at 7:16 PM the SA received a FRI and investigation about the 1/24/26 allegation of abuse for Resident 24. On 1/30/26 at 11:16 AM Staff 14 (LPN) stated she/he called Staff 2 the morning of 1/24/26 to report the Police were at the facility for an…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-02 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review it was determined the facility failed to ensure dependent residents received assistance with shaving for 1 of 4 sampled residents (#24) reviewed for ADLs. This placed residents at risk for lack of personal hygiene and loss of dignity. Findings include:The facility's 1/1/26 Activities of Daily Living Policy indicated a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene. The facility will maintain individual objectives of the care plan and periodic review and evaluation. Resident 24 was admitted to the facility in 6/2024 with diagnoses including dementia.Resident 24's 10/16/25 Care Plan revealed the following:-Staff were to set the resident up for daily hand and face washing and combing of hair and assist as needed. -The resident required assistance from one staff person with bathing. Resident 24's 1/2/26 Quarterly MDS revealed the resident was cognitively intact and required partial-to-moderate assistance from staff with…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-02 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to follow physician orders for 1 of 5 sampled residents (# 3) reviewed for unnecessary medications. This placed residents at risk for adverse side effects. Findings include:Resident 3 was admitted to the facility in 2/2023 with a diagnosis including chronic atrial fibrillation (irregular heart rhythm), diabetes and hyperlipidemia.Physician orders dated 11/2/25 indicated Resident 3 was prescribed the following medications:-Insulin aspart (fast-acting insulin)100 units/ml pen to be given before meals.-Insulin glargine Solostar (long-lasting insulin) 60 units every 12 hours.-Potassium citrate (helps prevent kidney stones) 2 tablets by mouth two times a day.-Senna Plus (bowel medication) two times a day.-Venlafaxine HCl (antidepressant) one time a day.-Gemfibrozil (treats high cholesterol) one time a day.-Metoprolol Succinate (treats high blood pressure) one time a day.-MiraLAX (bowel medication) one time a day.-Atorvastatin (treats high cholesterol) one time a day.-Digoxin (treats heart failure and abnormal…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review it was determined the facility failed to ensure physician orders and interventions were followed to reduce the risk of accidents for 1 of 1 sampled resident (#24) reviewed for food. This placed residents at risk for choking and aspiration. Findings include:The facility's 1/1/26 Accidents and Supervision Policy indicated the resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents, including monitoring for effectiveness and modifying interventions when necessary. Resident 24 was admitted to the facility in 6/2024 with diagnoses including oral dysphagia (difficulty chewing, manipulating and controlling food or liquid within the mouth using the tongue, lips and jaw) and oropharyngeal dysphagia (difficulty moving food from the mouth to the throat, often causing coughing, choking or food sticking in the throat). Resident 24's 7/3/24 SLP Evaluation and Plan of Treatment indicated the resident was not to use straws. Resident 24's…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-02 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review it was determined the facility failed to follow physician orders related to enteral (tube) feeding for 1 of 1 sampled resident (#13) reviewed for tube feeding. This placed residents at risk for complications related to the use of a feeding tube. Findings include: The facility's 1/1/26 Care and Treatment of Feeding Tubes Policy directed feeding tubes to be utilized according to physician orders, which typically included the kind of feeding and its caloric value, volume, duration, mechanism of administration and frequency of flush. Resident 13 was admitted to the facility in 1/2026 with diagnoses including other artificial openings of gastrointestinal tract status (the status of having an artificial opening [stoma] in the digestive tract that requires monitoring). Resident 13's 1/15/26 admission MDS revealed the resident was cognitively intact and used a feeding tube. Resident 13's 1/22/26 Physician Orders indicated the following:-The resident was to receive 65 ml of Jevity (a brand of fiber-fortified, therapeutic medical nutrition…

    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 · F2024-08-30 · 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 store and handle food in a manner to minimize cross contamination in 1 of 1 kitchen and 1 of 2 snack refrigerators reviewed for sanitary conditions. This placed residents at risk for foodborne illness. Findings include: 1. On 8/26/24 at 10:16 AM during the initial tour of the facility's kitchen, the following was observed in the walk in refrigerator and dry storage area: -Raw meat stored in the walk in refrigerator on a wire rack shelf directly above eggs and cartons of liquid whole eggs; and -Plastic handled scoops stored in the brown sugar, powdered sugar, white sugar and dry pasta storage bins. The scoops' handles touched the food in the bins. On 8/26/24 at 10:24 AM Staff 30 (Food Service Director) stated the meat in the refrigerator should be stored on the bottom shelf to avoid it dripping on the food below it and the scoops should be stored in their holsters to avoid cross contamination. Staff 30 stated, somebody just got lazy. 2. On 8/28/24 at 11:39 AM while plating foods for lunch…

    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 · E2024-08-30 · tag F0711 — pattern
    Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
    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's total program of care was reviewed and documented for 3 of 5 sampled residents (#s 4, 21 and 23) reviewed for medications. This placed residents at risk for unassessed medical needs and adverse side effects of medication. Findings include: 1. Resident 4 was admitted to the facility in 2020 with diagnoses including neuralgia (nerve pain). Resident 4's 3/2024, 5/2024 and 7/2024 provider visits, conducted and documented by Staff 29 (Gerontology Nurse Practitioner) were reviewed. The provider visit documentation lacked sufficient evidence to indicate the provider evaluated Resident 4's condition and reviewed the resident's total program of care. On 8/29/24 at 3:57 PM staff 29 stated she visited the residents at the scheduled times and as needed and was not sure where the documentation ended up in the residents' electronic health record. Staff 29 did not provide additional information in regard to her reviews, evaluations and documentation of Resident 4's total program of care. On 8/30/24 at…

    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 · E2024-08-30 · tag F0732 — pattern
    Post nurse staffing information every day.
    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 the ensure the Direct Care Staff Daily Report (DCSDR) postings were accurate for 16 of 27 days reviewed for staffing. This placed residents and visitors at risk for inaccurate staffing information. Findings include: Review of the 8/1/24 through 8/27/24 DCSDR indicated the following days when the number of hours CNAs and/or NAs worked were inaccurate on the daily postings: 8/1, 8/2, 8/3, 8/4, 8/5, 8/6, 8/9, 8/10, 8/11, 8/14, 8/19, 8/20, 8/23, 8/25, 8/26, and 8/27. On 8/29/24 at 8:24 AM Staff 17 (Staffing Coordinator) stated she did not fully understand how to complete the DCSDR and did not update the report to reflect changes that occurred in the schedules. On 8/29/24 at 10:10 AM Staff 1 (Administrator) stated she expected the DCSDR to be accurate.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-08-30 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined the facility failed to implement appropriate Enhanced Barrier Precautions (EBP) and failed to ensure appropriate use of PPE for 3 of 3 sampled residents (#s 3, 146, and 296) reviewed for infection control. This placed residents at risk for the spread of infection. Findings include: 1. The CDC's 4/3/24 website, section titled, Transmission Based Precautions, specified Contact Precautions are the second tier of basic infection control and are to be used in addition to Standard Precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission. Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain…

    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
Show the remaining 22 citations
  • Potential for harm · D2024-08-30 · 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

    Based on observation and interview it was determined the facility failed to ensure resident care equipment was in good repair for 1 of 4 sampled residents (#3) reviewed for environment. This placed residents at risk for uncomfortable and unsanitary care equipment. Findings include: Resident 3 was admitted to the facility in 2017 with diagnoses including multiple sclerosis (a degenerative disease). Resident 3's 7/19/24 Quarterly MDS indicated the resident was cognitively intact and used a wheelchair. Observations from 8/26/24 through 8/29/24 between the hours of 7:00 AM and 5:30 PM revealed Resident 3 to sit in her/his wheelchair. The wheelchair's left armrest vinyl covering was torn open approximately five inches with protruding sharp, rough edges. The wheelchair's right armrest vinyl covering was torn and cracked with protruding sharp, rough edges. Resident 3 stated she/he used the wheelchair everyday and the armrests were ugly and rough on her/his skin. On 8/29/24 at 11:05 AM Staff 6 (CNA) stated if resident care equipment was in disrepair, it was reported to maintenance. Staff 6…

    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 before2024-08-30 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, it was determined the facility failed to protect the resident's right to be free from physical abuse by a resident for 1 of 3 sampled residents (#16) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 16 was admitted to the facility in 1/2024 with diagnoses including stroke. Resident 16's admission MDS dated [DATE] revealed a BIMS score of 3, which indicated severe cognitive impairment. Resident 13 was admitted to the facility in 11/2023 with diagnoses including stroke and depression. Resident 13's Incident Note revealed on 7/6/24 Resident 16 was sitting near the nurses station not talking and Resident 13 yelled do not touch my chair or I am fucking going to let you have it. Resident 13 and 16 were separated and Resident 13 continued to yell out and cuss at residents and staff. Resident 13 was placed into her/his room. A 7/8/24 facility investigation report revealed Resident 13 and Resident 16 were near each other in the hallway near 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-30 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    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 document and conduct a significant change MDS assessment for 1 of 5 sampled residents (#13) reviewed for medications. This placed residents at risk for unassessed care needs. Findings include: Resident 13 was admitted to the facility in 11/2023 with diagnoses including stroke and depression. Review of the 11/9/24 admission MDS for Resident 13 revealed the following: -BIMS of 14 which indicated the resident was cognitively intact. -Substantial to maximal assistance with toileting hygiene, bathing self, sit to lying, lying to sitting, chair to bed transfer, toilet transfer, and shower transfer. -Partial to moderate assistance rolling left and right -Occasionally incontinent of bowel and bladder. -No physical restraints or alarms. Review of a 2/15/24 Alert Note indicated Resident 13 had a seizure lasting approximately three to four minutes. A new physician's order for topiramate (anticonvulsant) was prescribed. Review of a 2/15/24 New Prescription report indicated Resident 13 was prescribed topiramate for…

    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 · D2024-08-30 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 PASARR I (Pre-admission Screening/Resident Review) screening was completed prior to admission for 1 of 1 sampled resident (#25) reviewed for PASARR. This placed residents at risk for inappropriate placement in a nursing facility and lack of needed services. Findings include: Resident 25 admitted to the facility in 7/2024 with diagnoses including multiple sclerosis (a chronic disease of the central nervous system that interrupts the flow of information within the brain and between the brain and body) and major depressive disorder (a mental health disorder characterized by persistently depressed mood causing significant impairment in daily life). A review of Resident 25's 7/23/24 admission MDS revealed she/he was cognitively intact and required substantial assistance/was dependent on staff for the completion of her/his ADLs. No evidence was found in Resident 25's health record to indicate the facility completed a PASARR I prior to her/his admission to the facility. On 8/28/24 at 9:17 AM Staff 3…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-30 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure 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 facility staff failed to follow professional standards of practice for a diagnosis for 1 of 5 (#13) sampled residents reviewed for medications. Findings include: Resident 13 was admitted to the facility in 11/2023 with diagnoses including stroke and depression. A 11/9/23 admission MDS indicated Resident 13 was cognitively intact and did not have a diagnosis of seizure disorder or epilepsy. A review of Resident 13's current comprehensive care plan revealed no documentation of seizure disorder or epilepsy. Review of Resident 13's Alert Notes revealed the following: -2/14/24 on alert for new medication olanzapine (antipsychotic). -2/15/24 had a seizure at 10:50 AM lasting approximately three to four minutes. A new physician order for topiramate (anticonvulsant) was prescribed. -2/16/24 had a seizure on dayshift. New orders to increase topiramate. -2/18/24 sent to the emergency department because of confusion, and slurred speech. A review a 2/15/24 New Prescription report indicated Resident 13 was prescribed topiramate for epilepsy.…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-30 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 1 of 2 sampled residents (#13) reviewed for ADLs. This placed residents at risk for unmet needs. Findings include: Resident 13 was admitted to the facility in 11/2023 with diagnoses including a stroke and chronic pain. A 11/21/23 care plan indicated Resident 13 had a self-care deficit which required substantial assistance with ADL tasks including grooming. Review of the Documentation Survey Report on 8/26/24 revealed no documentation Resident 13 received personal hygiene on day shift or evening shift. On 8/26/24 at 10:55 AM, 8/27/24 at 12:44 PM and 8/28/24 at 9:16 AM Resident 13 was observed with a brown stain going from the left side of her/his mouth down to the bottom of her/his chin approximately one-half inch wide. On 8/28/24 at 9:19 AM Staff 8 (RCM Assistant) confirmed Resident 13's brown stain on her/his chin. On 8/30/24 at 8:42 AM Staff 1 (Administrator) and Staff 2 (Interim DNS) stated the expectation of staff were…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review it was determined the facility failed to ensure implementation of care plan interventions for 1 of 1 sampled resident (#23) reviewed for falls. This placed residents at risk for injury. Findings include: Resident 23 was admitted to the facility in 5/2019 with diagnoses including fracture of left lower leg, dementia, and high blood pressure. Resident 23's 7/24/24 quarterly MDS revealed the resident had a history of a fall. A review of progress notes revealed the resident reported an unwitnessed fall on 4/27/24. No injuries were noted. Review of Resident 23's Care Plan initiated 3/27/24 identified the resident was at risk for falls. Intervention revisions on 4/30/24 included a fall mat at the side of the bed. This intervention was also on the in room care plan. Observations on 8/26/24, 8/27/24, and 8/28/24 between 6:23 AM and 12:42 PM revealed a fall mat was not placed at the side of the bed. On 8/27/24 and 8/28/24 at 12:57 PM, 3:48 PM, and 9:24 AM Staff 19 (CNA), Staff 22 (NA), and Staff 23 (CNA) stated Resident 23 had an in 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-30 · tag F0694 — isolated
    Provide for the safe, appropriate administration of IV fluids 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 obtain a physician order and provide PICC (peripherally inserted central catheter) dressing care for 1 of 1 sampled resident (#146) reviewed for intravenous (IV) medications. This placed residents at risk for central catheter-related infections. Findings include: The 2011 CDC (Centers for Disease Control) guidelines on how to handle and maintain central lines specified to perform routine dressing changes every two to seven days and the CDC's Checklist for Prevention of Central Line Associated Blood Stream Infections specified to change semipermeable dressings at least every seven days. The facility's 3/2022 Peripheral and Midline IV Dressing Changes Policy and Procedure specified the following: - Maintain sterile dressing (transparent semi-permeable membrane [TSM] dressing for all peripheral catheter sites. - Change the dressing at least every seven days for TSM dressing. Resident 146 was admitted to the facility on [DATE]…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-30 · tag F0712 — isolated
    Ensure that the resident and his/her doctor meet face-to-face at all required visits.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review it was determined the facility failed to ensure residents were seen by a physician for 1 of 5 sampled residents (#13) reviewed for medications. This placed residents at risk for unmet medical needs. Findings include: Resident 13 was admitted to the facility in 11/2023 with diagnoses including a stroke and chronic pain. A review of Resident 13's clinical record indicated there were no physician visits documented since his/her admission. On 8/28/24 at 12:45 PM Staff 1 (Administrator) and Staff 3 (Social Services Supervisor) confirmed there was no physician visit for Resident 13 since admission.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-30 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide 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

    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 prescribed medications for 1 of 8 sampled residents (#147) reviewed for medications. This placed residents at risk for not receiving prescribed medications. Findings include: Resident 147 was admitted to the facility on [DATE] with diagnoses including pelvis fracture. Resident 147's 8/22/24 Physician Orders included the following: - Preservision AREDs 2 oral capsule by mouth in the morning; - Psyllium oral capsule 0.52 grams, 2 capsules in the evening; - Tolterodine Tartrate ER capsule 4 mg in the morning. Resident 147's 8/2024 MAR revealed Preservision AREDs 2 oral capsule, psyllium oral capsule and the tolterodine tartrate were marked 9 on 8/22/24, 8/23/24, 8/24/24, 8/25/24 and 8/26/24. On 8/27/24 at 9:44 AM Staff 7 (CMA) stated the 9 documented on the MAR meant the medication was not available. Staff 7 stated the pharmacy should be notified and the facility should get the medications as soon as…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-30 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to follow up on pharmacy recommendations for 1 of 5 sampled residents (#13) reviewed for medications. This placed residents at risk for adverse medication reactions. Findings include: Resident 13 was admitted to the facility in 11/2023 with diagnoses including insomnia. Resident 13's 6/7/24 Pharmacist's Report to Nursing revealed the following recommendation: -Resident 13 was ordered trazodone (to treat depression) at bedtime for insomnia and to administer one extra tablet if not asleep within one hour. Recommendations were to discontinue the current trazodone order and re-enter the order with scheduled and PRN portions separated so the administration could be charted on each portion. Resident 13's 6/2024 MAR revealed trazodone continued as previously ordered and the pharmacist's recommendations were not implemented. Resident 13's 7/8/24 Pharmacist's Report to Nursing revealed the following recommendation: -Resident 13 was ordered trazodone (to treat depression) at bedtime for insomnia and to administer one…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-30 · 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 interview and record review it was determined the facility failed to adequately monitor psychotropic medications for 1 of 5 sampled residents (#13) reviewed for medications. This placed residents at risk for lack of effective medication management. Findings include: Resident 13 was admitted to the facility in 11/2023 with diagnoses including insomnia, depression and pain. A 5/12/24 revised care plan indicated Resident 13 received psychotropic drugs which included fluoxetine for depression, trazodone for insomnia and olanzapine for depression. Interventions included to monitor and document the side effects and effectiveness of the medications every shift. No documentation was found in Resident 13's clinical record to indicate her/his medications' side effects and medication effectiveness were documented every shift. A review of Resident 19's signed Physician Order Summary Report dated 8/1/24 revealed the following medications: -Trazodone (for depression) 50 mg at bedtime for insomnia. -Olanzapine (an antipsychotic to treat severe agitation) 2.5 mg two times a day for…

    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 · Dcited before2023-05-08 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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 observation, interview and record review it was determined the facility failed to protect the resident's right to be free from physical abuse by a resident for 2 of 5 sampled residents (#s 159 and 23) reviewed for 4 allegations of resident-to-resident abuse. This placed residents at risk for abuse. Findings include: 1. Resident 157 was admitted to the facility in 8/2021 with diagnoses including dementia with behaviors and mixed receptive-expressive language disorder. Resident 157's 8/9/22 Annual MDS indicated she/he was not able to answer cognitive questions to assess a BIMS score. Staff assessed Resident 157 with short term memory problems and impaired decision-making skills. Resident 159 was admitted to the facility in 1/2016 with diagnoses including chronic heart failure. Resident 159's 4/1/22 Annual MDS indicated a BIMS score of 13 (cognitively intact). A FRI was submitted to the State Agency on 6/20/22 which revealed the following: On 6/20/22 Resident 159 used her/his foot to push Resident 157 away from her/his feet so her/his feet did not get run over by 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-08 · 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 complete a comprehensive assessment for 1 of 3 sampled residents (#51) reviewed for accidents. This placed residents at risk for unmet needs. Findings include: Resident 51 was admitted to the facility in 3/2023 with diagnoses including dementia with agitation. A review of Resident 51's 3/13/23 admission MDS ADLs Functional Status/Rehabilitation Potential, Urinary Incontinence and Indwelling Catheter and Nutritional Status CAAs identified the following problem areas: - Bed Mobility self-performance; - Transfer self-performance; - Walk in Room self-performance; - Walk in Corridor self-performance; - Locomotion On-Unit self-performance; - Dressing self-performance; - Eating self-performance; - Toilet Use self-performance; - Grooming/Personal Hygiene self-performance; - Bathing self-performance; - Urinary continence; - Weight was too low or too high and - Therapeutic Diet was indicated. The 3/13/23 Functional Status/Rehabilitation Potential, Urinary Incontinence and Indwelling Catheter and Nutritional Status…

    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 · D2023-05-08 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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 accurately code behaviors in resident MDS assessments for 1 of 3 sampled residents (#51) reviewed for accidents. This placed residents at risk for inaccurate assessments and unmet care needs. Findings include: Resident 51 was admitted to the facility in 3/2023 with diagnoses including dementia with agitation. A review of Resident 51's Progress Notes revealed the following: -On 3/10/23 the resident was found downstairs on the first floor looking for her/his room. A CNA brought her/him back to the second floor. -On 3/11/23 the resident was found downstairs by the doors leading to the outside of the facility. A Wander Guard (a bracelet worn by residents at-risk for wandering that sends an alert when residents get close to a monitored door) was placed on Resident 51's left ankle. A review of Resident 51's 3/13/23 admission MDS revealed the resident did not exhibit the behavior of wandering. On 5/3/23 at 1:42 PM Staff 4 (RNCM) stated Resident 51 had exhibited wandering since her/his admission to 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-08 · 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 observation, interview and record review it was determined the facility failed to develop a care plan for the use of a table tray for 1 of 2 sampled residents (#1) reviewed for physical restraints. This placed residents at risk for unmet needs. Findings include: Resident 1 was admitted to the facility in 1999 with diagnoses including quadriplegia (paralyzed). Resident 1's 3/22/23 Restraint/Adaptive Assessment indicated Resident 1 used a lap tray on her his wheelchair. Observations were made of Resident 1 with a lap tray on her/his wheelchair on 5/1/22 at 2:30 PM, 5/2/23 at 1:39 PM and 5/4/23 at 11:41 AM. On 5/4/23 at 1:09 PM Staff 17 (CNA) stated she referred to the resident's in-room care plan to determine the resident's care needs. Record review of Resident 1's 5/4/23 in room care plan did not indicate she/he used a lap tray. On 5/5/23 at 9:25 AM Staff 4 (RNCM) confirmed the lap tray was not included on the in-room care plan which directed staff when and how to use the lap tray. Staff 4 stated she expected items such as a lap tray to be on the in-room care plan so staff…

    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 · D2023-05-08 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined the facility failed to revise care plans in the areas of safety and fall prevention for 1 of 4 sampled residents (#51) reviewed for accidents. This placed residents at risk for repeated falls. Findings include: Resident 51 was admitted to the facility in 3/2023 with diagnoses including dementia with agitation. Resident 51's admission MDS indicated the resident was severely cognitively impaired, experienced a fall in the last month prior to admission, experienced a fall in the last two to six months prior to admission and experienced a fracture from a fall in the last six months prior to admission. Event Reports for Resident 51 revealed she/he experienced a fall on 3/21/23, 3/22/23, 3/24/23, 3/27/23, 4/15/23, 4/18/23, 4/21/23 and 4/29/23. The 3/21/23 Fall Investigation Report completed by Staff 2 (DNS) indicated the following care plan interventions remained appropriate and were followed: -Keep the bedroom door open as the resident allowed. -The resident was…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-08 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure 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 the services provided met professional standards of practice related to prescribing antipsychotic medication for 1 of 5 sampled residents (#10) reviewed for unnecessary medications. This placed residents at risk for unnecessary antipsychotic medications and adverse medication side effects. Findings include: OAR [PHONE NUMBER] Scope and Standards of Practice for All Licensed Advanced Practice Registered Nurses (APRN) indicated the following: - The APRN independently provides healthcare services within the scope of practice for which the APRN is educationally prepared and clinically trained with competency maintained in accordance with any other applicable rules, regulations, and prevailing standards. All standards and scope of practice found in OAR 851-045 related to the practice of Registered Nursing are applicable to APRNs. OAR [PHONE NUMBER] Scope of Practice Standards for Registered Nurses indicated the following: - Standards…

    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 · D2023-05-08 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review it was determined the facility failed to assess the root cause, notify the physician, obtain a treatment order, update the care plan, routinely monitor and implement a plan of care for a facility acquired pressure ulcer for 1 of 1 sampled resident (#10) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include: Resident 10 was admitted to the facility in 12/2022 with diagnoses including dementia and leg fracture. Resident 10's 3/14/23 Quarterly MDS and 3/27/23 Significant Change MDS indicated the resident had an unhealed Stage II (open wound) pressure ulcer and required pressure ulcer care. A 3/5/23 Wound Management Detail Report, completed by Staff 24 (former LPN), indicated the resident had an area of necrotic (dead) tissue which measured 3 cm in length and 3.5 cm in width on her/his left heel. The Report did not include a root cause analysis to determine how or when the wound developed, whether the provider was notified, if wound treatment was provided or needed or if the care plan…

    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 · D2023-05-08 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to identify and comprehensively assess weight loss and ensure weights were monitored for 2 of 3 sampled residents (#s 42 and 51) reviewed for nutrition. This placed residents at risk for unidentified weight changes. Findings include: The facility's Weight Assessment and Intervention Policy and Procedure, revised 3/2022, instructed the following: -Residents were weighed upon admission and at established intervals; -Weights were recorded in each individual's medical record and on the unit weight record; -Any weight change of five percent or more since last weight assessment was retaken the next day for confirmation. 1. Resident 51 was admitted to the facility in 3/2023 with diagnoses including dementia with agitation and lung cancer. Resident 51's admission MDS indicated she/he was severely cognitively impaired. Resident 51's 3/15/23 Initial Nutritional Assessment completed by Staff 16 (RD) revealed the resident's oral intake was very good at each meal and she/he met her/his nutritional needs. The Assessment…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-08 · 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 residents were assessed appropriately before administration of an anti-psychotic medication for 1 of 5 sampled residents (# 10) reviewed for unnecessary medications. This placed residents at risk for unnecessary medication adverse side effects. Findings include: The facility's 7/2022 Psychotropic Medication Use Policy & Procedure specified the following: - Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record; - Consideration of the use of any psychotropic medication is based on comprehensive review of the resident. This includes evaluation of the resident's signs and symptoms in order to identify underlying causes; - Non-pharmacological approaches are used to minimize the need for medications; - When determining whether to initiate, modify or discontinue medication therapy, the [interdisciplinary team]…

    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 · D2023-05-08 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for 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 provide routine dental services for 1 of 1 sampled resident (#6) reviewed for dental needs. This placed residents at risk of unmet dental needs. Findings include: Resident 6 was admitted to the facility in 6/2020 with diagnoses including stroke. A review of Resident 6's 4/17/23 Annual MDS revealed she/he was cognitively intact. On 5/2/23 at 9:45 AM Resident 6 was observed to have several missing upper front teeth. Many of her/his remaining native teeth appeared decayed, broken and grey. Resident 6 stated she/he was independent when completing oral care and had a history of multiple extractions. A review of Resident 6's progress notes revealed she/he was assessed by a dentist on 11/29/21. The dentist recommended extracting the resident's remaining teeth and fitting her/him for dentures. Resident 6 declined this treatment due to her/his preference for implants. The dentist recommended the resident return for further treatment. No additional notes were found in Resident 6's electronic health…

    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

“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

$52,030 in federal fines across 1 penalty.

  • $52,030 — penalty dated 2026-02-02

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

Who owns this facility

Owner / managerTypeRoleShareSince
WASCO COUNTY NURSING CARE, INC.Organization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL100%since 03/11/1997
OLMSTEAD, AUBREEIndividualCORPORATE DIRECTORsince 06/13/2016
COURTNEY, DAVIDIndividualCORPORATE OFFICERsince 03/11/1997
OMEG, LINDAIndividualCORPORATE OFFICERsince 03/11/1997
TRAUTZ, LINDAIndividualCORPORATE OFFICERsince 03/01/2018
SNYDER, KIMBERLYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 02/01/2015

CMS files one row per role, so the 7 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$9.2M
Net patient revenuemost recent cost report
-13.4%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 74%Medicare 8%Other / private 17%

About 74% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$576per resident / day
operating cost
$17,502per month
≈ monthly operating cost
$508per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in OR

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 385049. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-02, 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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