LIFE BYVardellNursing Home
Report

TheVardellReport

South Hills Rehabilitation Center

Skilled nursing facility and nursing facility

1166 E. 28Th Avenue
Eugene, OR 97403

Report Date
Nov 1, 2026
Data Through
Oct 1, 2026
Report ID
VR-OR-385167-2611
← South Hills Rehabilitation Center, free profile

Life by Vardell Presents

The Vardell Report.South Hills Rehabilitation Center

The deeper story, beautifully organized. Available records, historical context, and questions worth asking.

Provider Category
Nursing home
Location
Eugene, OR
Record Period
2019–2026
Source Documents
11
Read the report

This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.

01

The Essentials

Summary

Across 9 inspections from April 2019 to August 2026, state surveyors documented 76 findings at South Hills Rehabilitation Center; 74 have a recorded correction and 2 await one; CMS lists 3 enforcement actions in the window.

Inspections
9
2019–2026, complaint and standard
Findings
76
Deficiencies cited by state inspectors
Corrected
74
Of 76 findings, with a recorded correction date
Penalties
3
3 fines; payment not published

Findings by Year

  • Findings
  • Of which, actual harm (level G or above)
2019: 8 findings across 1 inspection820191 inspection2020: 0 findings across 0 inspections020200 inspections2021: 0 findings across 0 inspections020210 inspections2022: 0 findings across 0 inspections020220 inspections2023: 0 findings across 0 inspections020230 inspections2024: 41 findings across 2 inspections4120242 inspections2025: 13 findings across 2 inspections; of which, actual harm (level G or above): 11320252 inspections2026: 14 findings across 4 inspections; of which, actual harm (level G or above): 2142026*4 inspections2019: 8 findings across 1 inspection820191 insp.2020: 0 findings across 0 inspections020200 insp.2021: 0 findings across 0 inspections020210 insp.2022: 0 findings across 0 inspections020220 insp.2023: 0 findings across 0 inspections020230 insp.2024: 41 findings across 2 inspections4120242 insp.2025: 13 findings across 2 inspections; of which, actual harm (level G or above): 11320252 insp.2026: 14 findings across 4 inspections; of which, actual harm (level G or above): 2142026*4 insp.

* Partial year, through October 1, 2026.

Findings by year
YearInspectionsFindingsOf which, actual harm (level G or above)
2019180
2020000
2021000
2022000
2023000
20242410
20252131
20264142
02

Chronology

Inspection History

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

  1. 2026

    Complaint investigation

    2 findings

    • F627Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
    • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  2. 2026

    Complaint investigation

    8 findings

    • F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Level JImmediate jeopardyCorrected Aug 25, 2026
    • F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Level ENo actual harm, potential for moreCorrected Aug 25, 2026
    • F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.Level ENo actual harm, potential for moreCorrected Aug 25, 2026
    • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Aug 25, 2026
    • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Aug 25, 2026
    • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Aug 25, 2026
    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Aug 25, 2026
    • F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.Level DNo actual harm, potential for moreCorrected Aug 25, 2026

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  3. 2026

    Complaint investigation

    3 findings

    • F584Honor 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.Level ENo actual harm, potential for moreCorrected Jun 2, 2026
    • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Jun 2, 2026
    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jun 2, 2026

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  4. 2026

    Complaint investigation

    1 finding

    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level GActual harmCorrected Mar 24, 2026

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  5. 2025

    Complaint investigation

    2 findings

    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jan 5, 2026
    • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Jan 5, 2026

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  6. 2025

    Standard health inspection

    11 findings

    • F880Provide and implement an infection prevention and control program.Level LImmediate jeopardyCorrected Sep 29, 2025
    • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Sep 29, 2025
    • F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Sep 29, 2025
    • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Sep 29, 2025
    • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Sep 29, 2025
    • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Sep 29, 2025
    • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Sep 29, 2025
    • F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Level DNo actual harm, potential for moreCorrected Sep 29, 2025
    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Sep 29, 2025
    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Sep 29, 2025
    • F814Dispose of garbage and refuse properly.Level DNo actual harm, potential for moreCorrected Sep 29, 2025

    Enforcement Action

    Civil money penalty, $79,238 imposed August 11, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of August 11, 2025, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $28,870 imposed February 9, 2026. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of August 11, 2025, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $57,888 imposed July 15, 2026. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of August 11, 2025, the nearest before the penalty date.

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  7. 2024

    Complaint investigation

    8 findings

    • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level ENo actual harm, potential for moreCorrected Dec 5, 2024
    • F732Post nurse staffing information every day.Level ENo actual harm, potential for moreCorrected Dec 5, 2024
    • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Dec 5, 2024
    • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Dec 5, 2024
    • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Dec 5, 2024
    • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Dec 5, 2024
    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Dec 5, 2024
    • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Dec 5, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  8. 2024

    Standard health inspection

    33 findings

    The same visit included a complaint investigation.

    • F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Level ENo actual harm, potential for moreCorrected May 8, 2024
    • F565Honor the resident's right to organize and participate in resident/family groups in the facility.Level ENo actual harm, potential for moreCorrected May 8, 2024
    • F576Ensure residents have reasonable access to and privacy in their use of communication methods.Level ENo actual harm, potential for moreCorrected May 8, 2024
    • F577Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.Level ENo actual harm, potential for moreCorrected May 8, 2024
    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level ENo actual harm, potential for moreCorrected May 8, 2024
    • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level ENo actual harm, potential for moreCorrected May 8, 2024
    • F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Level ENo actual harm, potential for moreCorrected May 8, 2024
    • F730Observe each nurse aide's job performance and give regular training.Level ENo actual harm, potential for moreCorrected May 8, 2024
    • F758Implement 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.Level ENo actual harm, potential for moreCorrected Jun 22, 2024
    • F814Dispose of garbage and refuse properly.Level ENo actual harm, potential for moreCorrected May 8, 2024
    • F851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.Level ENo actual harm, potential for moreCorrected May 8, 2024
    • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Jun 22, 2024
    • F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected May 8, 2024
    • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected May 8, 2024
    • F584Honor 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.Level DNo actual harm, potential for moreCorrected May 8, 2024
    • F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Level DNo actual harm, potential for moreCorrected May 8, 2024
    • F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Level DNo actual harm, potential for moreCorrected May 8, 2024
    • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected May 8, 2024
    • F637Assess the resident when there is a significant change in conditionLevel DNo actual harm, potential for moreCorrected May 8, 2024
    • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected May 8, 2024
    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Jun 22, 2024
    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected May 8, 2024
    • F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Level DNo actual harm, potential for moreCorrected May 8, 2024
    • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected May 8, 2024
    • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected May 8, 2024
    • F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected May 8, 2024
    • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected May 8, 2024
    • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected May 8, 2024
    • F776Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.Level DNo actual harm, potential for moreCorrected May 8, 2024
    • F791Provide or obtain dental services for each resident.Level DNo actual harm, potential for moreCorrected May 8, 2024
    • F809Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.Level DNo actual harm, potential for moreCorrected May 8, 2024
    • F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.Level DNo actual harm, potential for moreCorrected May 8, 2024
    • F881Implement a program that monitors antibiotic use.Level DNo actual harm, potential for moreCorrected May 8, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  9. 2019

    Standard health inspection

    8 findings

    • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected May 21, 2019
    • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected May 21, 2019
    • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected May 21, 2019
    • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected May 21, 2019
    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected May 21, 2019
    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected May 21, 2019
    • F791Provide or obtain dental services for each resident.Level DNo actual harm, potential for moreCorrected May 21, 2019
    • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected May 21, 2019

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

03

Context

Patterns Worth Examining

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

  1. 1

    Quality of Care, Cited in Six Inspections

    Inspectors cited F684 in April 2019, March 2024, August 2025, December 2025, February 2026 and April 2026. This citation covers whether residents receive the treatment their orders, preferences and goals call for. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    192424252526262626F684 across all 9 inspections, oldest to newest
  2. 2

    Reporting Suspected Abuse, Cited in Four Inspections

    Inspectors cited F609 in March 2024, October 2024, August 2025 and July 2026. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    192424252526262626F609 across all 9 inspections, oldest to newest
  3. 3

    Telling Families About Changes, Cited in Three Inspections

    Inspectors cited F580 in March 2024, August 2025 and July 2026. This citation covers whether the resident, their doctor and a family member are told promptly about an injury, a decline or another significant change. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    192424252526262626F580 across all 9 inspections, oldest to newest
  4. 4

    Investigating Alleged Violations, Cited in Three Inspections

    Inspectors cited F610 in April 2019, October 2024 and August 2025. This citation covers how the home responds to and investigates an allegation of abuse, neglect or mistreatment. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    192424252526262626F610 across all 9 inspections, oldest to newest
  5. 5

    Help With Daily Living, Cited in Three Inspections

    Inspectors cited F677 in April 2019, March 2024 and October 2024. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    192424252526262626F677 across all 9 inspections, oldest to newest
  6. 6

    Accident Hazards and Supervision, Cited in Three Inspections

    Inspectors cited F689 in March 2024, August 2025 and July 2026. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    192424252526262626F689 across all 9 inspections, oldest to newest
  7. 7

    Infection Control, Cited in Three Inspections

    Inspectors cited F880 in April 2019, March 2024 and August 2025. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. The most serious of these was recorded at level L (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    192424252526262626F880 across all 9 inspections, oldest to newest
  8. 8

    Residents Taking Their Own Medication, Cited in Two Inspections

    Inspectors cited F554 in March 2024 and August 2025. This citation covers whether a resident who keeps and takes their own medication has been assessed as safe to do so. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    192424252526262626F554 across all 9 inspections, oldest to newest
  9. 9

    A Clean, Homelike Setting, Cited in Two Inspections

    Inspectors cited F584 in March 2024 and April 2026. This citation covers whether rooms and shared spaces are kept safe, clean, comfortable and homelike. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    192424252526262626F584 across all 9 inspections, oldest to newest
  10. 10

    Protection From Abuse and Neglect, Cited in Two Inspections

    Inspectors cited F600 in October 2024 and August 2025. This citation covers whether residents are protected from abuse and neglect by anyone. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    192424252526262626F600 across all 9 inspections, oldest to newest
  11. 11

    Nursing Staff Levels, Cited in Two Inspections

    Inspectors cited F725 in March 2024 and October 2024. This citation covers whether there are enough nurses and aides to meet residents’ needs, with a licensed nurse in charge on each shift. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    192424252526262626F725 across all 9 inspections, oldest to newest
  12. 12

    Provide or obtain dental services for each resident, Cited in Two Inspections

    Inspectors cited F791 in April 2019 and March 2024. The agency describes it this way: Provide or obtain dental services for each resident. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    192424252526262626F791 across all 9 inspections, oldest to newest
  13. 13

    Garbage and Refuse, Cited in Two Inspections

    Inspectors cited F814 in March 2024 and August 2025. This citation covers whether garbage and refuse are disposed of properly. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    192424252526262626F814 across all 9 inspections, oldest to newest
  14. 14

    Citation F849, Cited in Two Inspections

    Inspectors cited F849 in March 2024 and July 2026. The agency describes it this way: Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    192424252526262626F849 across all 9 inspections, oldest to newest
  15. 15

    Citation F627, No Recorded Correction

    F627 was cited in August 2026. The agency describes it this way: Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. The most serious was level D (no actual harm, potential for more). The August 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

    192424252526262626F627 across all 9 inspections, oldest to newest
  16. 16

    Care Plan Timing and Review, No Recorded Correction

    F657 was cited in April 2019, March 2024 and August 2026. This citation covers whether care plans are written on time and revised by a team that includes the resident’s caregivers. The most serious was level D (no actual harm, potential for more). The August 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

    192424252526262626F657 across all 9 inspections, oldest to newest
04

For Your Next Visit

Questions to Ask on Your Visit

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

  1. 01

    How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?

    Quality of Care: cited in six inspections, most seriously at level G.

  2. 02

    How are staff trained to report suspected abuse or neglect, and who reports it to the state?

    Reporting Suspected Abuse: cited in four inspections, most seriously at level D.

  3. 03

    How quickly will we hear about a fall, an injury or a change in condition, and from whom?

    Telling Families About Changes: cited in three inspections, most seriously at level D.

  4. 04

    When an allegation is made, who investigates it, and how are residents protected in the meantime?

    Investigating Alleged Violations: cited in three inspections, most seriously at level D.

  5. 05

    How long do residents usually wait for help with bathing, dressing or the bathroom, and how is that tracked?

    Help With Daily Living: cited in three inspections, most seriously at level D.

  6. 06

    What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?

    Accident Hazards and Supervision: cited in three inspections, most seriously at level E.

  7. 07

    Who leads infection control here, and how often are hand-hygiene and isolation practices audited?

    Infection Control: cited in three inspections, most seriously at level L.

  8. 08

    How do you decide whether a resident may keep and take their own medications?

    Residents Taking Their Own Medication: cited in two inspections, most seriously at level D.

  9. 09

    What was done about the cleanliness citation, and how are rooms and shared spaces checked now?

    A Clean, Homelike Setting: cited in two inspections, most seriously at level E.

  10. 10

    What happened after the abuse or neglect citation, and what changed in training or supervision?

    Protection From Abuse and Neglect: cited in two inspections, most seriously at level D.

  11. 11

    How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

    Nursing Staff Levels: cited in two inspections, most seriously at level E.

  12. 12

    What changed after F791 was cited, and how do you check it now?

    Provide or obtain dental services for each resident: cited in two inspections, most seriously at level D.

  13. 13

    How is waste handled around the kitchen and resident areas?

    Garbage and Refuse: cited in two inspections, most seriously at level E.

  14. 14

    What changed after F849 was cited, and how do you check it now?

    Citation F849: cited in two inspections, most seriously at level D.

  15. 15

    What changed after F627 was cited, and how do you check it now?

    Citation F627: cited in one inspections, most seriously at level D. The August 18, 2026 citation has no recorded correction date.

  16. 16

    How often are care plans revised, and who takes part in the review?

    Care Plan Timing and Review: cited in three inspections, most seriously at level D. The August 18, 2026 citation has no recorded correction date.

  17. 17

    What led to the 2026 fine, and has it been paid?

    A $57,888 civil money penalty was imposed July 15, 2026. CMS publishes the fine, not whether it has been paid. The record holds three enforcement actions in the window.

05

The Evidence

Sources and Coverage

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Oregon state survey agency.

  • Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

    Oregon state survey agency

    Inspection Apr 5, 2019 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

  • Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

    Oregon state survey agency

    Inspection Mar 22, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

  • Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

    Oregon state survey agency

    Inspection Oct 16, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

  • Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

    Oregon state survey agency

    Inspection Aug 11, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

  • Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

    Oregon state survey agency

    Inspection Dec 9, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

  • Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

    Oregon state survey agency

    Inspection Feb 9, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

  • Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

    Oregon state survey agency

    Inspection Apr 13, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

  • Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

    Oregon state survey agency

    Inspection Jul 15, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

  • Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

    Oregon state survey agency

    Inspection Aug 18, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

  • Penalties, Provider Data Catalog

    Centers for Medicare & Medicaid Services

    Published Oct 1, 2026 · Retrieved Nov 1, 2026

    View Dataset ↗
  • Provider Information, Provider Data Catalog

    Centers for Medicare & Medicaid Services · 385167

    Published Oct 1, 2026 · Retrieved Nov 1, 2026

    View Dataset ↗

Coverage

Record windowApril 5, 2019 – October 1, 2026

  • CMS publishes about three inspection cycles; inspections before April 2019 are not in this release.
  • CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.

What This Report Cannot Tell You

Complaints not investigated onsite
Allegations screened out by the state before an onsite visit are not published.
Complaint allegations
CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
Facility-reported incidents
Self-reported incidents appear only if they led to an inspection.
Follow-up visits
CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
Fire safety inspections
Published by CMS separately and not included in this record yet.
Staffing levels and ownership history
Published by CMS separately and not included in this record.
Whether fines were paid
CMS publishes the fines imposed, not whether or when they were paid.

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.