Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Gardens Of St. Francis during CMS and state inspections, most recent first.
A facility failed to document monitoring for the effectiveness, side effects, and adverse effects of psychotropic medications for four residents receiving antidepressant, antianxiety, antipsychotic, and mood-stabilizing drugs. Records showed no monitoring documentation for residents with conditions including depression, anxiety, dementia, bipolar disorder, and psychotic disturbance, and the DON confirmed the lack of monitoring. Facility policy required documentation of resident response and adverse effects, but the reviewed charts did not reflect this.
Vaccination Records Not Up to Date: The facility failed to keep influenza and pneumococcal immunizations current for five reviewed residents. Records showed multiple residents with significant medical histories such as COPD, CKD, dementia, HF, and respiratory conditions had incomplete or outdated vaccine documentation, including one resident whose pneumococcal vaccine had not been offered and another with no evidence that influenza vaccine was offered on admission. The DON confirmed the missing or not up-to-date immunization records.
A resident with multiple chronic conditions, including COPD, myasthenia gravis, epilepsy, dementia-related impairment, and CHF, was routinely awakened around 5:00 A.M. for ADLs and placement in a wheelchair despite preferring to sleep in. Staff interviews and a handwritten overnight get-up list showed the resident was scheduled to be washed, dressed, and up early, while the DON and ADON were unaware of the list and the RP stated the resident should be left sleeping if asleep.
PASARR Not Completed Before Admission: A resident admitted with dementia, bipolar disorder, major depressive disorder, anxiety disorder, and severe cognitive deficits had no PASARR completed before admission. The MDS noted wandering behaviors, and the care plan included distraction for wandering plus antidepressant and psychotropic meds as ordered. The DOM confirmed a search of the electronic system found no PASARR prior to admission.
Failure to Apply Ordered TED Hose: A resident with severe dementia and dependent ADL needs had physician-ordered TED hose for edema, but repeated observations showed the stockings were not on the resident’s legs despite TAR documentation indicating they were applied. The ADON verified the omission, and an RN stated CNAs apply and remove the stockings while nursing staff document verification in the TAR.
Failure to implement ordered pressure injury prevention measures affected three residents at risk for skin breakdown. One resident with multiple chronic conditions developed an open area on the right buttock that was later documented as a stage 2 pressure ulcer, while staff did not document assessment or treatment changes before the wound physician evaluation. Two other residents had orders for heel protectors, but observations showed the devices were not in use, and an RN confirmed they should have been.
Failure to Monitor Psychotropic Medication Effects and Side Effects
Penalty
Summary
The facility failed to ensure adequate monitoring for psychotropic medication effectiveness, side effects, and adverse effects for four residents reviewed for unnecessary medications. The report states that the facility had 39 residents receiving psychotropic medications and that the deficiency involved residents #16, #6, #38, and #68. Review of the medical records, nurses’ notes, MARs, TARs, staff interview, and facility policy showed no documentation that these residents were being monitored for the effectiveness or adverse effects of their psychotropic medications. Resident #16 had diagnoses including major depression and anxiety disorder, with a care plan addressing mood disorder, crying episodes, refusals of care, and refusal to eat when upset. Orders included lamotrigine, sertraline, and duloxetine for depression and anxiety, but there were no orders for monitoring medication effectiveness, adverse effects, or side effects. Review of records from 01/01/26 through 03/25/26 found no documentation of monitoring, and the DON verified that no such documentation existed. Resident #6 had diagnoses including unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, bipolar disorder, major depressive disorder, and anxiety disorder. The resident had a BIMS score of 3 and wandering behaviors. Orders included Lexapro for anxiety and Risperdal for bipolar disorder, and the care plan called for monitoring and reporting adverse reactions of psychotropic medications, but no order was entered to monitor side effects and the DON confirmed monitoring was not being done. Resident #38 had diagnoses including hemiplegia and hemiparesis following cerebral infarction, major depressive disorder, chronic embolism and thrombosis of deep veins, and contracture of joint; the resident was cognitively intact and received sertraline and buspirone, but records from 02/22/26 through 03/25/26 showed no monitoring documentation. Resident #68 had diagnoses including type II diabetes, protein calorie malnutrition, muscle wasting, cognitive communication deficit, anxiety disorder, major depressive disorder, Alzheimer’s disease, and peripheral vascular disease; the resident was moderately cognitively impaired, on hospice, and ordered mirtazapine, lorazepam, Ativan, and Seroquel, yet the facility record contained no evidence of psychotropic side effect monitoring during the reviewed periods. The facility policy required documentation of the resident’s response to psychotropic medications and any adverse side effects or refusals, but this was not reflected in the records reviewed.
Vaccination Records Not Up to Date
Penalty
Summary
The facility failed to ensure pneumococcal and influenza vaccinations were up to date for five of five residents reviewed for immunizations. Medical record reviews, staff interviews, and review of facility policies showed that Residents #13, #17, #33, #36, and #56 did not have vaccination records that were current or properly documented. The facility census was 57. Resident #13 was admitted with diagnoses including cardiomegaly, HTN, type 2 DM, stage 3B CKD, COPD, and obstructive sleep apnea. His quarterly MDS indicated he was cognitively impaired, required moderate assistance with ambulation and ADLs, had chronic lung disease, and experienced shortness of breath when lying down; the assessment stated his pneumococcal vaccine was up to date. Resident #17 was admitted with diagnoses including hemiplegia and hemiparesis following a stroke, muscle weakness, dementia, stage three CKD, anxiety, depression, and a personal history of brain cancer. Her quarterly MDS indicated she used a walker independently up to 50 feet, required set-up to moderate assistance with ADLs, experienced shortness of breath when lying down, had received influenza vaccine outside the facility, and her pneumococcal vaccine was up to date. Resident #33 was admitted with diagnoses including dementia, dysphagia, HTN, hyperlipidemia, muscle wasting, protein-calorie malnutrition, pain to lower extremities, and reduced mobility. Her quarterly MDS indicated cognitive impairment, no behaviors or refusals of care, wheelchair use, dependence for transfers and mobility, and maximal to dependent ADL assistance; it also stated her pneumococcal vaccine was up to date. Resident #36 was admitted with acute respiratory failure with hypoxia, HF, pleural effusion, OSA, SOB, and type 2 DM; her quarterly MDS showed moderate cognitive impairment, verbal behavioral symptoms toward others, wheelchair use, dependence for transfers and mobility, maximal ADL assistance, and SOB while lying down, but stated her pneumococcal vaccine was not up to date because it had not been offered. Resident #56 was admitted with retroperitoneal hematoma, CKD, a non-pressure chronic ulcer of the right lower leg, atrial fibrillation, dilated cardiomyopathy, AV block, HF, iron deficiency anemia, intestinal malabsorption, and type 2 DM; her admission assessment showed she was alert and oriented, pleasant and cooperative, and at risk for skin breakdown. Review of her influenza immunization record showed no evidence that she received the vaccine and no documentation that it was offered when she was admitted. Review of pneumococcal immunization records for Residents #13, #17, #33, #36, and #56 showed their pneumococcal immunizations were not up to date. The DON confirmed that pneumococcal immunizations for Residents #13, #17, #33, and #36 were not up to date and confirmed there was no documentation that Resident #56 received the influenza vaccine or that it was offered on admission.
Resident’s Preference to Sleep In Was Not Respected
Penalty
Summary
The facility failed to respect a resident’s preference to sleep in and instead woke the resident early in the morning for ADLs and placement in a wheelchair. Resident #16 was admitted with multiple diagnoses including COPD, myasthenia gravis, epilepsy, dysphagia, major depression, hypertension, anxiety disorder, CAD, insomnia, CHF, and neurofibromatosis. The most current MDS described moderately impaired cognition, no resistive behaviors, dependence for completion of ADLs, and wheelchair use propelled by staff. A revised plan of care addressed weakness, balance problems, muscle atrophy, cognitive deficit, and immobility, with interventions including two-person assist with Hoyer lift and anticipation of needs. During interview, Resident #16 stated staff woke them early in the morning, provided morning ADLs, and placed them in the wheelchair at about 5:00 A.M., even though they preferred to sleep in. A CNA stated the resident was woken at 5:15 A.M., dressed, groomed, and left in bed, and also noted the resident was resistant at times. A handwritten instruction sheet identified get-ups for the overnight shift and listed Resident #16 to be washed and dressed in bed, then placed in the wheelchair at 5:00 A.M., with a note to try again or get the nurse if the resident refused. The DON and ADON stated they were unaware of the get-up list, and the resident’s RP stated that if the resident was sleeping, they should be left sleeping.
PASARR Not Completed Before Admission
Penalty
Summary
Failure to have a required PASARR completed prior to admission occurred for one resident. The resident was admitted with diagnoses including unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, bipolar disorder, major depressive disorder, and anxiety disorder. The quarterly MDS dated 02/04/26 documented a BIMS score of 3, indicating severe cognitive deficits, and also noted wandering behaviors one to three days a week. The admission care plan dated 07/31/25 included interventions for staff to distract the resident from wandering and to administer antidepressant and psychotropic medications as ordered by the physician. Review of the medical record found no PASARR completed before admission, despite the resident having mental illness diagnoses. During interview on 03/25/26 at 11:03 A.M., the DOM stated a search of the Healthcare Electronic Notification System was unable to find that a PASARR had been completed prior to 03/24/26 and verified that the resident did not have a PASARR completed prior to admission. The facility policy titled Resident Assessment- Coordination of PASARR Program, dated 03/01/23, stated all applicants will be screened for serious mental disorders or intellectual disabilities and related conditions, and that the initial pre-screening would be completed prior to admission.
Failure to Apply Ordered TED Hose
Penalty
Summary
The facility failed to apply anti-emboli stockings (TED hose) as ordered for one resident with severe cognitive impairment and significant assistance needs for personal care. The resident had diagnoses including unspecified dementia without behavioral disturbance, muscle wasting and atrophy, generalized osteoarthritis, rheumatic tricuspid insufficiency, and cardiomegaly. The care plan identified the resident as at risk for edema of the lower extremities and included interventions for applying support stockings and elevating the legs. Physician orders directed TED hose to be applied to both lower extremities every day for edema and removed at bedtime. Review of the TAR showed TED hose were documented as applied in the mornings and removed in the evenings, including on two specific mornings. However, observations on multiple occasions showed the resident sitting in a recliner in the common area without TED hose on the lower extremities. The ADON verified the resident did not have TED hose on as ordered. RN #407 stated CNAs are responsible for placing TED hose in the morning and removing them at bedtime, and that nurses are responsible for documenting application in the TAR; when asked about the resident’s TED hose on one morning, the RN stated he had not yet verified placement, despite his initials being entered on the TAR as verification that the TED hose were in place.
Failure to Implement Ordered Pressure Injury Prevention Measures
Penalty
Summary
Failure to provide pressure ulcer prevention measures was identified for three residents who were at risk for skin breakdown. Resident #3 had multiple diagnoses including CHF, HTN, CKD stage 3, depression, atrial fibrillation, osteoporosis, anemia, impaired lower extremity function, frequent urinary incontinence, and dependence for many ADLs. The care plan addressed skin integrity concerns related to incontinence, decreased mobility, and fragile skin, and an air mattress was ordered for pressure reduction. During observation, an open area of skin breakdown was noted on the right buttock with scant blood-tinged drainage and triad paste residue in place, but the record showed no evidence that the wound was assessed or that treatment was modified before the wound physician later documented a stage 2 pressure ulcer. Resident #3 also had an air mattress order, but the physician order did not include mattress settings or function. When the wound physician assessed the resident, the air mattress setting was decreased from 250 pounds to 180 pounds. During interview, an LPN stated maintenance staff placed the air mattresses on the beds and nurses observed them in place, and the LPN was unaware whether mattress settings were required or how to ensure proper function. This reflected that the ordered pressure-reduction support was not being monitored in a way that ensured it was functioning as intended. Resident #33 and Resident #56 also had pressure injury prevention orders for heel protectors, but observations showed the devices were not in use. Resident #33, who was cognitively impaired, dependent for transfers and mobility, and at risk for pressure injuries, had an order for heel protectors to both feet every shift, yet she was observed in her wheelchair and later in bed without them. Resident #56, who was alert and oriented and at risk for skin breakdown, had an order for heel protectors when in bed or in a recliner, but she was observed resting in bed without them. In both cases, an RN confirmed the heel protectors were not on and should have been. The facility policy stated resident-specific interventions would be implemented to prevent pressure injuries.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Oregon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ayden Healthcare Of Oregon | 1.3 mi | ★★★★★ | 11 | 0 |
| Orchard Villa | 2.7 mi | ★★★★★ | 0 | 0 |
| Arbors At Oregon | 2.8 mi | ★★★★★ | 9 | 1 |
| Majestic Care Of Toledo Snf | 3.3 mi | ★★★★★ | 6 | 0 |
| Majestic Care Of Point Place | 7 mi | ★★★★★ | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.