Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Curry Village Health And Rehab Of Cascadia during CMS and state inspections, most recent first.
RN Staffing Shortage: The facility failed to provide 8 consecutive hours of RN coverage per day on 6 reviewed days. Direct care staffing records showed no 8-hour RN coverage on those days, and the Administrator acknowledged the lack of RN coverage. The report stated this placed residents at risk for unmet assessment needs.
Improper Hand Hygiene and Food Handling in Kitchen: Staff were observed washing hands incorrectly by using a paper towel to turn off the faucet and then drying with the same towel, changing gloves and resuming tasks without re-washing, and handling juice and dish covers without proper hand hygiene. A Dietary Aide, Cook, Culinary Manager, and Dietary Manager were involved in observations showing repeated lapses in sanitation and food handling practices, and staff reported they had not received recent hand hygiene training.
Failure to Obtain Assessment and Informed Consent for Tab Alarm: A resident with Alzheimer's disease and cognitive impairment had a tab alarm in use, but the clinical record contained no assessment or informed consent for the device. An RN and the DNS both stated that an evaluation and informed consent were required before use, but neither document could be found in the resident's record.
Incomplete MDS Assessments for Resident Preferences, Mood, Cognition, and Pain: The facility failed to complete required MDS sections for three residents. One resident with heart failure had an incomplete Section F on a significant change MDS, another resident with pain and behavioral diagnoses had incomplete Sections C, D, F, and J on an annual MDS, and a third resident admitted with sepsis had an incomplete Section F on the admission MDS. The MDS Coordinator and Activity Director confirmed the missing assessments.
Failure to administer scheduled pain meds per MD orders for a resident admitted with rib fractures. The resident was alert and able to communicate needs, but the MAR showed missed doses of Tylenol and Robaxin after admission. The DON stated the orders were not verified until later that evening, and the Corporate RN verified Robaxin was available in the automated med dispensing system. The resident reported not receiving all pain meds until the next morning and being very painful.
Two residents, both cognitively intact but with significant medical histories, were involved in a physical altercation after one resident threatened to harm the other. Despite a request for a room change and intensified monitoring, the facility did not follow its policy for urgent relocation, resulting in one resident physically assaulting the other and both requiring hospital care.
The facility failed to ensure proper food storage, preparation, and handling, risking foodborne illnesses. Observations revealed unlabeled and undated items in refrigerators and freezers, improper use of gloves, and lack of cleanliness in the kitchen. Staff demonstrated inadequate adherence to food safety protocols, and the facility lacked a cleaning schedule.
The facility did not ensure that food for residents on pureed diets was prepared to preserve nutritional value. Pureed cranberry chicken was served, and staff used water to achieve the texture, determining consistency by sight. The culinary manager stated that guidelines from Sysco were used, but the survey team did not receive these. Sysco's guidelines recommend using gravy, sauce, broth, or milk for pureeing and a two-step testing method for texture.
A resident with paralysis of the lower body, who was cognitively intact and had no swallowing difficulties, was observed taking medications without supervision in the dining room. The RN stated the resident preferred to self-administer medications during meals. However, the facility failed to conduct a self-medication administration assessment, as confirmed by the Chief Nursing Officer and Clinical Resource.
A resident with Alzheimer's and diabetes did not receive required assistance with personal hygiene and bathing due to a lack of staff assignment and communication. The resident, who had severe cognitive impairment, was observed with long facial hair and expressed a desire for shaving assistance. Staff were unclear about the process for shaving diabetic residents, and the responsible staff member for bathing assignments had left unexpectedly, leading to the oversight.
The facility failed to prevent unnecessary psychotropic medication use and did not monitor side effects for two residents. One resident received Xanax beyond the prescribed period due to a lack of documentation, while another resident on trazodone was not monitored for side effects as required. Staff interviews confirmed these deficiencies.
A facility failed to maintain a medication error rate below 5%, resulting in a 7.41% error rate. A resident admitted with malnutrition was prescribed Ferrous Sulfate EC and Calcium with Vitamin D. An LPN administered the wrong dose of iron and omitted the Calcium with Vitamin D due to a transcription error on the MAR, which was not caught during order verification.
A resident with incomplete quadriplegia and dementia did not receive the required range of motion (ROM) exercises as outlined in their care plan. The care plan specified passive ROM during morning and evening care, but the task was not included in the current Kardex, leading to staff not performing the exercises. Interviews with staff confirmed the oversight, and the Chief Nursing Officer acknowledged that CNAs were capable of performing ROM but were not doing so.
RN Staffing Shortage
Penalty
Summary
The facility failed to staff a registered nurse for 8 consecutive hours per day, 7 days per week, for 6 of 122 days reviewed for staffing. A review of the Direct Care Staff Daily Reports for 10/1/25 through 10/31/25, 11/1/25 through 11/31/25, 12/1/25 through 12/31/25, and 4/1/26 through 4/30/26 showed that on 10/4/25, 11/22/25, 12/27/25, 4/4/26, 4/11/26, and 4/18/26 there were no 8 consecutive hours of RN coverage on any shift in a 24-hour period. On 5/7/26 at 10:53 AM, Staff 1, the Administrator, acknowledged there was no RN coverage on those days. The report stated this placed residents at risk for unmet assessment needs.
Improper Hand Hygiene and Food Handling in Kitchen
Penalty
Summary
The facility failed to ensure staff followed correct sanitation and food handling procedures to prevent the outbreak of foodborne illness in the kitchen. During observation, a Dietary Aide washed her hands but used a paper towel to turn off the faucet and then dried her hands with the same paper towel. A Cook was observed buttering rolls and then moving to a new task, while another staff member changed gloves between tasks but did not re-wash her hands before removing gloves, going to the walk-in refrigerator, and pouring juice for a resident that was then given to another staff person without hand hygiene first. Additional observations showed the Culinary Manager washing his hands and also using a paper towel to turn off the faucet and then drying his hands with the same paper towel. Later, the Dietary Aide delivered a food cart to a resident hall and returned to the kitchen to resume prepping lunch trays without washing her hands. The Cook removed her gloves, left the steam table, performed another task, then returned to the steam table and re-gloved without washing her hands. The Dietary Aide also carried dish covers pressed against her clothing from the dishwashing area back to the tray line and resumed setting up trays without washing her hands; those dish covers were then used on plates going out to residents. Staff stated they had not received recent training on hand hygiene, and the Dietary Manager stated staff should wash their hands after changing gloves or touching contaminated surfaces and acknowledged she had not recently observed kitchen staff for proper hand hygiene.
Failure to Obtain Assessment and Informed Consent for Tab Alarm
Penalty
Summary
The facility failed to ensure that a resident was given the right to make informed treatment decisions for Resident 20, who was admitted with a diagnosis of Alzheimer's Disease and had a BIMS score of 5, indicating cognitive impairment. The resident's clinical record showed use of a tab alarm, but no assessment or informed consent for the tab alarm was found in the record. Staff 9, an RN, stated that an assessment should be completed before using a tab alarm and that consent must be obtained from the resident or the resident's representative, and Staff 2, the DNS, stated that nursing staff should complete an evaluation and obtain informed consent before using a tab alarm, but could not find either document in the resident's record.
Incomplete MDS Assessments for Resident Preferences, Mood, Cognition, and Pain
Penalty
Summary
The facility failed to ensure MDS assessments were completed for 3 of 8 sampled residents reviewed for pain, unnecessary medications, and activities. Resident 2 was admitted with heart failure, and the 2/24/26 Significant Change in Status MDS showed Section F, preferences for routine and activities, was not assessed. Staff 3, the MDS Coordinator, confirmed the activity section was incomplete, and Staff 5, the Activity Director, stated she completed the activity evaluation and submitted it to the MDS coordinator, but did not know the preferences for routine and activities section was incomplete. Resident 39 was admitted with diagnoses including pain and personality and behavioral disorders, and the 2/8/26 Annual MDS had Sections C, D, F, and J not assessed. Staff 3 confirmed the cognition, mood, activity, and pain sections were incomplete and stated she notified the DNS. Resident 29 was admitted with sepsis, and the 4/19/26 admission MDS had Section F, preferences for routine and activities, not assessed. Staff 5 stated she was responsible for interviewing residents for Section F and verified the section was not completed for Resident 29; Staff 3 stated the information was not available before the ARD and she was not able to complete Section F.
Failure to Administer Scheduled Pain Medication
Penalty
Summary
The facility failed to administer pain medications per physician orders for one resident admitted with rib fractures. The resident’s hospital discharge medication list ordered Tylenol every six hours for 10 days and Robaxin every six hours for 10 days. The resident was admitted to the facility at 4:30 PM, was alert, able to communicate needs, and reported pain only with movement. The MAR showed Tylenol and Robaxin scheduled for 6:00 PM, 12:00 AM, 6:00 AM, and 12:00 PM, but Robaxin was not administered at 6:00 PM or 12:00 AM, and Tylenol was not administered at 6:00 PM. The resident stated that after being admitted at approximately 5:00 PM, not all pain medication was received until the morning of the next day and that the resident was very painful. The DNS stated that if a resident had scheduled pain medication, staff should administer it if available in the facility, and that Tylenol was always stocked. The DNS also stated nurses did not verify the resident’s orders until approximately 7:00 PM, so the 6:00 PM Tylenol dose was not given, and the resident did not receive any pain medication until 12:00 AM. The Corporate RN verified that Robaxin was available in the automated medication dispensing system and staff should have pulled it from the system to administer to the resident.
Failure to Prevent Resident-to-Resident Physical Abuse Following Missed Room Change
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. One resident, who had a history of stroke and lack of coordination and was cognitively intact, made a statement about intending to harm their roommate, who also had cognitive impairment and cancer but was cognitively intact. Following this threat, intensified monitoring with 15-minute checks was initiated, and a room change request was submitted to Social Services. However, there was no follow-up on the room change request, and the mandated relocation did not occur as scheduled. As a result of the facility's failure to adhere to its policy regarding urgent room changes in situations involving threats of resident-to-resident aggression, the resident who made the threat physically assaulted their roommate, causing facial injuries that required emergency room care. Both residents were subsequently sent to the hospital after the incident, and emergency services and police were called. The administrator acknowledged that immediate relocation and physician notification were required when a resident threatens to harm another resident, but these actions were not taken in a timely manner.
Food Safety and Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure proper food storage, preparation, and handling, which put residents at risk for foodborne illnesses. During an initial kitchen observation, several items in the walk-in refrigerator and freezer were found without labels or open dates, including various dairy products, meat, and a pie. Additionally, trays of hamburger patties were uncovered, and a cutting board with dark spots was in use. Staff members were observed not following proper procedures, such as not wearing gloves or cleaning thermometers between uses, and there was a lack of knowledge about food storage and glove-wearing policies. Further observations revealed that the issues persisted, with undated and unlabeled items still present in the refrigerators and freezer. Staff members, including the Culinary Manager and Dietary Aids, demonstrated a lack of adherence to food safety protocols, such as wearing gloves and maintaining cleanliness. The facility also lacked a cleaning schedule or audits for the kitchen, contributing to the ongoing deficiencies in food safety and hygiene practices.
Failure to Preserve Nutritional Value in Pureed Diets
Penalty
Summary
The facility failed to ensure that food for residents on pureed texture diets was prepared in a manner that preserved its nutritional value. During an observation of the lunch meal service, it was noted that pureed cranberry chicken was served as a main course. A dietary aide revealed that water was used to create the puree texture, and the consistency was determined by sight. The culinary manager confirmed that the kitchen staff were instructed to use water for pureeing and mentioned that recipes and texture guidelines were sourced from Sysco. However, the survey team did not receive the promised recipes and guidelines. A review of Sysco's website indicated that pureed foods should be mixed with gravy, sauce, broth, or milk, and a two-step testing method should be used to determine the texture before serving.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure a resident was assessed for the ability to self-administer medications, which was observed during dining observations. The resident, admitted in June 2006 with a diagnosis of paralysis of the lower body, was cognitively intact and had no difficulty swallowing as per the quarterly MDS dated January 19, 2025. On January 30, 2025, the resident was observed sitting alone in the dining room with 12 medications placed on a napkin next to their breakfast tray, without staff supervision to ensure the medications were taken. Staff 10, an RN, stated that the resident preferred to take medications while eating and was left alone during meals. Staff 2, the Chief Nursing Officer, and Staff 3, the Clinical Resource, confirmed that a self-medication administration assessment was not completed and was not present in the resident's clinical record. The resident expressed a preference for taking medications independently and confirmed no issues with swallowing or interruptions during meals.
Failure to Provide Required ADL Assistance
Penalty
Summary
The facility failed to ensure that a dependent resident received the required assistance with activities of daily living (ADLs), specifically personal hygiene and bathing. Resident 36, who was admitted with Alzheimer's disease and diabetes, had a severe cognitive impairment as indicated by a BIMS score of six. The resident's care plan required partial to moderate assistance with personal hygiene and bathing. However, documentation revealed that on a scheduled bathing day, the resident was not assigned to a staff member for bathing, and there was no record of the resident being offered or refusing a bath. Additionally, the resident expressed a desire to have facial hair removed, but staff were unaware of the process for residents without an electric razor. Observations and interviews highlighted that the resident had approximately two-inch long facial hair and could not recall the last time they received a shower. Family members were unaware that staff could assist with facial hair removal. Staff interviews revealed confusion about the process for shaving diabetic residents and a lack of communication regarding the assignment of bathing duties. The Chief Nursing Officer acknowledged that the staff member responsible for the bathing assignment sheet had left unexpectedly, resulting in the missed shower for the resident.
Failure to Monitor Psychotropic Medication Use and Side Effects
Penalty
Summary
The facility failed to ensure that residents did not receive unnecessary psychotropic medications and did not adequately monitor for side effects in two cases. Resident 7, who was admitted with an anxiety disorder, had a physician's order for Xanax to be administered every eight hours as needed for anxiety, with a specified duration of 90 days. However, the medication was administered eight times beyond the prescribed end date, as the end date was not documented in the Medication Administration Record (MAR). Staff interviews confirmed that the end date should have been documented in the clinical records. Resident 28, admitted with a diagnosis of cancer, was receiving trazodone daily at bedtime for sleep. The care plan indicated a goal for the resident to be free from adverse reactions such as sedation, agitation, and confusion. However, the MAR and Treatment Administration Record (TAR) did not include monitoring for side effects of the antidepressant. Observations showed the resident was alert and interacting with others, but staff interviews revealed that side effect monitoring was not documented as required. The Chief Nursing Officer and Clinical Resource verified the lack of documentation for monitoring psychotropic side effects.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 7.41% error rate with two errors in 27 opportunities. Resident 92, admitted with a diagnosis of malnutrition, was prescribed Ferrous Sulfate EC 324 mg and Calcium with Vitamin D. However, on the day following admission, an LPN administered the incorrect dose of iron, providing only 45 mg of Slow Iron, and failed to administer the Calcium with Vitamin D. This error occurred because the Calcium with Vitamin D order was not transcribed onto the Medication Administration Record (MAR) by the medical records staff, and the nurse did not catch the omission during the order verification process. The Chief Executive Officer and Chief Nursing Officer were informed of the transcription error, and the medical records staff acknowledged the oversight.
Failure to Provide Required ROM Exercises for Resident
Penalty
Summary
The facility failed to ensure that a resident received the necessary range of motion (ROM) exercises, as outlined in their care plan. Resident 18, who was admitted with incomplete quadriplegia, dementia, and blindness, required assistance with activities of daily living (ADLs) and had functional limitations in ROM for both arms and legs. The care plan, initiated in November 2024, specified that staff should provide passive ROM during morning and evening care. However, the current Kardex, which guides CNAs on resident-specific care, did not include a task for ROM exercises for Resident 18. Interviews with staff revealed a lack of implementation of the care plan's directives. Staff 17, a CNA, stated that ROM tasks would be performed if they were listed on the Kardex, but they were not. Staff 14, an occupational therapist, noted that Resident 18 was discharged from therapy services due to poor pain tolerance and insight, and the facility did not have a restorative aide program. Staff 4, a Resident Care Manager RN, acknowledged that the care plan required ROM exercises, but they were not included in the Kardex, and thus, not performed by the staff. The Chief Nursing Officer confirmed that CNAs were capable of performing ROM but were not doing so for Resident 18.
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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 Brookings
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crescent City Care Center | 20.1 mi | ★★★★★ | 33 | 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 August 2026) and official state health department websites.