Above average — CMS composite of the measures below.
The next survey window likely opens around February 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 Life Care Center Of Mcminnville during CMS and state inspections, most recent first.
Insufficient nursing staff caused morning medications to be given late, with an LPN stating medications were almost always delayed because there were not enough nurses and that she was still passing meds while several residents had not yet received theirs. A resident with convulsions and dementia had multiple scheduled meds, and the DNS acknowledged the resident’s morning meds were administered late along with two other residents missing meds at that time; the expected morning med pass time was by 10:00 AM.
Repeated Late Administration of Time-Sensitive Parkinson's Medication: A resident with Parkinson's disease and moderate cognitive impairment received Carbidopa-Levodopa on a q3h schedule, but multiple doses were given outside the one-hour grace period. The resident and family member reported that late doses led to tremors and a reactionary state, and staff could not explain why the time-sensitive medication was repeatedly administered late.
An open Humalin N insulin pen was found in a treatment cart without an open date, and two open vials of Tuberculin in the med room refrigerator were also undated. The med refrigerator temperature logs were blank on multiple dates while it stored flu vaccines, insulin, and other meds, and an LPN and the DNS acknowledged the missing labels and incomplete temperature documentation.
Expired food was found in 2 unit refrigerators, and temperature logs were not maintained. One refrigerator contained moldy food, salad, milk, and kefir past their use-by or best-by dates, while the snack refrigerator contained expired kefir and thickened food. The DTR acknowledged the items should have been discarded and stated food in unit refrigerators was to be removed after 3 days.
Call lights were not kept within reach for two residents who were at risk for falls and had care plans requiring the call light to be accessible. One resident’s call light was found behind a pillow, under a blanket, and looped behind the bed rail, while another resident’s call light was found on the floor under the bed and later attached to the bed rail while the resident was in a wheelchair and unable to reach it. Staff stated call lights should always be within reach.
Inaccurate assessment of functional mobility for a resident with stroke-related left hemiparesis. The resident had documented flaccidity and no independent movement in the left arm and leg, but the admission MDS incorrectly coded no functional limitation in UE ROM. Later observation showed the resident's left arm fixed at 90 degrees, and the RN MDS Coordinator stated the admission MDS was coded inaccurately.
Failure to provide personal hygiene services for a resident who required substantial to total assistance with ADLs. The resident had stroke, TBI, moderate cognitive impairment, and one-sided upper extremity impairment, yet staff documented hand hygiene assistance while the resident was repeatedly observed with soiled fingernails over several days. A CNA stated fingernails could be cleaned during or after a shower, but did not clean under the nails, and an LPN said daily nail cleaning was expected.
Failure to Provide Ordered Pain Management: A resident with a stroke history and falls history had a care plan for pain relief and orders for PRN acetaminophen and a warm compress, but there were no documented pain interventions or PRN med administrations over several days. The resident reported neck and shoulder pain, requested a warm towel, later rated the pain as 8 or 9 out of 10, and said the pain left the resident fatigued and unable to fully participate in therapy; staff acknowledged the pain reports, and the DNS confirmed no documented pain interventions.
Three residents discharged from the facility did not have complete discharge summaries. The documentation for each lacked essential information such as home instructions, recapitulation of the stay, and, in one case, the name of the home health provider. The DNS confirmed these assessments were not thoroughly completed.
A resident with a colostomy and malnutrition was admitted with an abdominal wound, but the facility did not complete weekly wound assessments despite ongoing symptoms of redness, inflammation, and worsening skin breakdown. Staff confirmed that no wound assessments were performed during the resident's stay.
A resident with a colostomy and multiple chronic conditions experienced ongoing leakage from the ostomy site, resulting in severe skin breakdown and pain. Despite frequent wound care by staff and repeated reports of the issue, physician documentation and assessment did not address the skin condition, leading to the resident's hospitalization for extensive skin damage. The deficiency was due to inadequate physician supervision and failure to evaluate the effectiveness of wound care treatments.
A survey revealed a 23% medication error rate in an LTC facility, with errors in dosage and timing for residents' medications. One resident received incorrect doses of duloxetine and Eliquis, and another was given the wrong dose of sertraline. Staff acknowledged the errors, but no further information was provided by the DNS.
A resident with left-sided hemiparesis required assistance with ADL care, including fingernail care. Despite the care plan indicating the need for assistance, the resident was observed with long fingernails and reported requesting nail trimming, which was not provided. A CNA confirmed that nail care was offered on shower days and acknowledged the resident's dependency on staff for nail care. The DNS also observed the resident's long fingernails and confirmed that nail care had not been completed.
A resident with left-sided hemiparesis following a stroke did not receive a restorative program to prevent decline in range of motion after being discharged from therapy. Despite expressing a desire to participate in such a program, the facility did not offer restorative services, and staff acknowledged the resident would have benefited from them.
A facility failed to provide appropriate dialysis care for a resident by not completing required Pre/Post Dialysis Communication Forms and neglecting to check the resident's dialysis access site daily as per the care plan. The forms were not completed multiple times over several months, and there was no documentation of the required daily checks of the resident's chest wall dialysis access site. Staff confirmed these oversights.
The facility failed to address pharmacy recommendations for two residents, leading to a deficiency in medication management. One resident's haloperidol dose reduction was delayed by 13 days, while another resident's Eliquis order was not updated timely. The DNS acknowledged the lack of a system to ensure timely implementation of pharmacy recommendations.
The facility did not promptly address concerns raised in Resident Council meetings for two out of three months reviewed, risking unresolved quality of life and care issues. Despite policy requirements for prompt action and follow-up, there was no response to issues such as call light accessibility, dietary needs, and room cleanliness. The Activities Director distributed meeting notes to department heads, but no responses were received, contrary to the Administrator's expectations for timely feedback.
Insufficient Nursing Staff Led to Late Medication Administration
Penalty
Summary
Sufficient nursing staff were not provided each day to meet resident needs and ensure a licensed nurse was in charge on each shift, resulting in medications being administered late. The 2/19/26 Resident Council Minutes stated nurses were rushing during medication pass. On 3/9/26 at 11:55 AM, Staff 4, an LPN, stated the resident's morning medications were administered late almost every day because there were not enough nursing staff. On 3/10/26 at 11:26 AM, Staff 4 stated she was running behind and was still passing morning medications, and that three residents had not received their morning medications. Resident 59 was admitted in 2023 with diagnoses including unspecified convulsions and dementia. The 3/2/26 physician orders included acetaminophen three times daily, cyanocobalamin once daily, sennosides-docusate sodium once daily, carvedilol twice daily, duloxetine once daily, levetiracetam once daily, aspirin once daily, amlodipine once daily, and cholecalciferol once daily. Staff 4 was observed administering these morning medications to Resident 59, and on 3/12/26 at 8:16 AM, Staff 2, the DNS, acknowledged the medications had been administered late to Resident 59 on 3/11/26 at 11:26 AM and acknowledged there were two additional residents who did not receive medications at that time. Staff 2 stated the expectation was for morning medications to be administered by 10:00 AM.
Repeated Late Administration of Time-Sensitive Parkinson's Medication
Penalty
Summary
The facility failed to ensure that Resident 53 was free from significant medication errors related to Carbidopa-Levodopa administration. Resident 53 was admitted with Parkinson's disease and orthostatic hypotension, had a BIMS score of 12 indicating moderate cognitive impairment, and was assessed as being at risk for falls and needing assistance with mobility and ADLs. The admission physician order prescribed 1.5 tablets of Carbidopa-Levodopa 25-200 mg every 3 hours, and the facility scheduled the medication for administration at 2:00 AM, 5:00 AM, 8:00 AM, 11:00 AM, 2:00 PM, 5:00 PM, 8:00 PM, and 11:00 PM. A timestamped medication administration history from 3/1/26 through 3/10/26 showed 18 of 76 administrations exceeded the one-hour grace period. During observation, the resident was seen sleeping in bed with a family member at bedside and periodically sat up, punched into the air, and had all-over body tremors. The family member stated concern about the timing of the Carbidopa-Levodopa. The resident stated the timing of the Parkinson's medication was very important and that late doses could cause a reactionary state, including flailing arms, jitteriness, anxiety, fear, and disorientation; the resident also reported being in such a state earlier that morning because the medication was given late and that the resident hit a heel on the bed edge, causing pain. Staff acknowledged the one-hour grace period and that Carbidopa-Levodopa was time sensitive, but could not provide a reason for the repeated late administrations. The Medical Director acknowledged possible increased rigidity or tremors if the medication was given more than one hour outside the scheduled time, and the DNS stated staff was not used to giving medications with specific administration times.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with accepted professional principles and that medication storage temperatures were properly logged and maintained. During observation of the C hall treatment cart, an open Humalin N insulin pen was found with no open date, and Staff 3 (LPN) acknowledged that it was open and unlabeled. The Director of Nursing later stated that insulin pens were expected to be labeled with open dates. In the medication room refrigerator, two open vials of Tuberculin were observed without open dates, and Staff 3 (LPN) acknowledged that both vials were open and not labeled. The manufacturer’s instructions indicated the medication should be discarded 30 days after opening. The medication refrigerator temperature logs were also observed to be blank on multiple dates while the refrigerator contained flu vaccines, insulin, and other medications. Staff 3 acknowledged the blank logs, and the DNS stated that the refrigerator temperature was expected to be checked and logged twice daily.
Expired Food Stored in Unit Refrigerators
Penalty
Summary
Food items stored in the unit refrigerators were found expired, and refrigerator temperatures were not being monitored for 2 of 2 unit refrigerators reviewed. On 3/9/26, the ADL kitchen refrigerator contained a temperature log with only one documented temperature for 1/14/26 and no entries for January, February, or March, along with an individual to go container dated 2/22/26, a snack pack with moldy food and a use by date of 2/25/26, a bagged salad with a use by date of 2/25/26, a half-gallon of milk with a best by date of 2/4/26, and two kefir containers with best by dates of 1/16/26 and 12/26/25. Staff 12 confirmed the expired contents and the temperature log. On 3/9/26, the snack refrigerator contained a kefir dated 2/26/26 and a carton of thick and easy with a use by date of 8/14/25, and Staff 15 observed the items. Staff 11 stated food stored in the unit refrigerators was to be removed after three days and acknowledged the items should have been discarded.
Call lights not kept within residents’ reach
Penalty
Summary
The facility failed to ensure call lights were within reach for two residents who were identified as being at risk for falls and needing their call lights within reach. Resident 85 was admitted with diagnoses including malnutrition, leg fracture, and a history of falls. The care plan and MDS indicated the resident required assistance with mobility and had no cognitive impairment. During observations, the resident’s call light was found behind the resident attached to the back of a pillow and out of reach, later attached to the outside of the bed under a blanket and out of the resident’s line of sight, and later looped to the bed rail behind the resident so it could not be located when the resident needed to use the bathroom. Resident 86 was admitted with diagnoses including stroke and a history of falls, and the care plan identified the resident as high risk for falls with the call light needing to be within reach. Nursing notes described the resident as alert, oriented, and able to make needs known. During observation, the resident’s call light was found under the bed on the floor while the resident was in bed, and later it was attached to the bed rail while the resident was in a wheelchair and unable to reach it because of the distance and the oxygen nasal cannula. Staff stated that call lights were to always be within reach and not on the floor or across the room.
Inaccurate Assessment of Functional Mobility
Penalty
Summary
The facility failed to accurately assess functional mobility for one resident with left side hemiparesis. The resident was admitted in 5/2025 with a history of stroke-related left side hemiparesis, and a hospital H&P documented that the resident had left side hemiparesis. A progress note from 5/18/25 stated the resident's left side was very flaccid with no strength or independent movement to the arm or leg. However, the 5/23/25 admission MDS indicated the resident did not have a functional limitation in range of motion in the upper extremities. During observation on 3/8/26, the resident's left arm was seen bent at 90 degrees, and the resident stated that the arm could not be moved because of a stroke. On 3/11/26, the RN MDS Coordinator stated that the resident had limited ROM in the left upper extremity on admission and that the admission MDS was coded inaccurately.
Failure to Provide Personal Hygiene Services
Penalty
Summary
The facility failed to provide personal hygiene services for one resident who was unable to perform activities of daily living. The resident was admitted with diagnoses including stroke and traumatic brain injury, had a care plan indicating the need for assistance with ADLs, and the admission MDS showed a BIMS score of 9, indicating moderate cognitive impairment. The resident also had one-sided upper extremity impairment and required substantial to maximum assistance with personal hygiene activities. The ADL personal hygiene task, including hand hygiene, was documented as completed with extensive assistance on one day and total dependence on subsequent days, and the resident received a shower during that period. However, the resident was observed multiple times over several days with soiled fingernails and a brown substance underneath all fingernails on the right hand. Staff stated that fingernails could be cleaned at any time and were not limited to morning hygiene tasks or a shower, and one CNA acknowledged giving the resident a shower but not cleaning under the fingernails. An LPN later stated the expectation was for resident fingernails to be cleaned daily and that it was unacceptable for a resident to have dirty fingernails multiple days in a row.
Failure to Provide Ordered Pain Management
Penalty
Summary
The facility failed to provide pain management for one resident who had diagnoses including stroke and a history of falls. The resident’s care plan dated 3/6/26 included a goal for the resident to express pain relief and to receive pain medication as ordered. Physician orders included acetaminophen 500 mg every six hours as needed for pain on 3/6/26 and a warm compress (washcloth) as needed for pain on 3/9/26. Nursing notes from 3/7/26, 3/8/26, and 3/10/26 described the resident as alert, oriented, and able to make needs known. The treatment administration record showed pain ratings of zero on 3/8/26, 3/9/26, 3/10/26, and 3/11/26, and there were no documented uses of the warm compress from 3/9/26 through 3/11/26. The medication administration record showed no administrations of PRN acetaminophen during that same period. Despite this documentation, the resident stated on 3/9/26 that she/he had pain on the left side of the neck and shoulder and had requested a warm towel from staff. The resident later reported pain rated 8 or 9 out of 10, said no one brought the warm towel, stated she/he had been in tears the previous night due to pain, and reported ongoing neck pain that caused fatigue and interfered with therapy participation. Staff acknowledged the resident had reported pain, but the DNS confirmed there were no documented pain interventions from 3/8/26 through 3/11/26.
Incomplete Discharge Summaries for Discharged Residents
Penalty
Summary
The facility failed to complete thorough discharge summaries for three residents who were discharged during the review period. For one resident admitted with a femur fracture and discharged home with home health services, the discharge summary did not specify the home health company, lacked post-discharge instructions, and omitted a recapitulation of the resident's stay. Another resident admitted with respiratory failure and discharged home did not have home instructions or a recapitulation of their stay included in the discharge summary. Similarly, a third resident admitted with anemia and discharged home was missing home instructions and a recapitulation of their stay in the discharge summary. In each case, the Director of Nursing Services confirmed that the discharge summary information assessments were not completed thoroughly.
Failure to Assess and Document Worsening Abdominal Wound
Penalty
Summary
The facility failed to assess and document a skin wound for a resident with a colostomy and malnutrition, who was admitted with an abdominal ostomy site showing erythema and skin breakdown. Although the hospital history and physical noted the wound, the facility's admission skin assessment did not indicate any abdominal wounds. Progress notes over several days described the resident's abdominal skin as red, inflamed, excoriated, blistered, and tender, with constant drainage and irretractable pain. Despite these ongoing symptoms and the worsening condition, no weekly wound assessments were completed from admission through the resident's transfer to the hospital and subsequent return. Facility staff confirmed that no wound assessments were performed during this period.
Failure to Ensure Physician Oversight of Wound Care for Resident with Colostomy
Penalty
Summary
The facility failed to ensure that a physician adequately supervised a resident's medical care and evaluated the effectiveness of wound care treatments for a resident with a colostomy and multiple chronic conditions, including atrial fibrillation and malnutrition. Upon admission, the resident had an abdominal ostomy site with surrounding erythema and skin breakdown. Care plans were in place to protect the skin from ostomy drainage, but physician documentation did not address the leaking ostomy or the condition of the surrounding skin. Progress notes over several days described persistent leakage, red and inflamed skin, and worsening excoriation, with staff frequently reporting the issue and providing wound care, but without effective resolution or physician intervention regarding the skin condition. The resident's condition deteriorated, resulting in extensive skin breakdown, maceration, and severe pain, ultimately requiring hospital transfer for evaluation and treatment. Hospital records confirmed significant skin damage related to ostomy leakage. Upon readmission, physician notes continued to omit assessment of the skin surrounding the colostomy site. Interviews with staff confirmed ongoing issues with the colostomy bag and skin integrity, and the physician acknowledged focusing on other medical concerns and not assessing the abdominal wound. The lack of physician oversight and failure to address the persistent skin issues led to the deficiency.
Medication Errors Exceeding 5% in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 23% error rate. This was observed during a survey where six errors were identified in 26 opportunities. The errors involved incorrect dosages and administration times for medications prescribed to residents. For instance, Resident 152, who was admitted with heart failure, GERD, and fibromyalgia, was given incorrect doses of duloxetine and Eliquis, and omeprazole was administered after breakfast instead of before. Additionally, Tylenol was administered late, and cetirizine was prepared instead of the prescribed loratadine. Another incident involved Resident 10, who was admitted with major depressive disorder. The resident was prescribed sertraline 100 mg daily, but Staff 3 prepared only 50 mg. These errors were identified by a State Surveyor, and the staff involved acknowledged the discrepancies. The Director of Nursing Services (DNS) was informed of these findings but provided no additional information.
Failure to Provide Necessary Fingernail Care
Penalty
Summary
The facility failed to provide necessary assistance with fingernail care for a resident who was unable to perform this activity independently. The resident, who was admitted in 2024 with a diagnosis of stroke and left-sided hemiparesis, required assistance with activities of daily living (ADL) due to left-sided weakness. According to the care plan dated August 7, 2024, the resident needed help with ADL care. Although the treatment administration record (TAR) indicated that the resident received nail care on October 31, 2024, an observation on November 4, 2024, revealed that the resident had long fingernails and had requested nail trimming, which was not provided by the staff. On November 6, 2024, a CNA confirmed that nail care was typically offered on shower days and acknowledged the resident's dependency on staff for nail care, noting the resident's long fingernails. The Director of Nursing Services (DNS) also observed the resident's long fingernails and confirmed that nail care had not been completed.
Failure to Provide Restorative Program for Resident with Hemiparesis
Penalty
Summary
The facility failed to provide a restorative program to prevent decline in range of motion for a resident who was admitted with diagnoses including stroke and left-sided hemiparesis. The resident's care plan indicated left-sided weakness and impaired mobility, requiring assistance with activities of daily living. Despite making consistent progress in physical and occupational therapy, the resident's upper extremity hemiparesis did not improve, and the therapy discharge summaries noted that a restorative program was not indicated at that time. However, the resident expressed a desire to participate in a restorative program and reported not receiving range of motion exercises for their hand. Staff confirmed that the resident was a good candidate for restorative services post-therapy discharge due to the stroke and difficulty using the left hand. The facility did not offer a restorative program, and staff were unsure of when such services were last provided, acknowledging that the resident would have benefited from them.
Failure to Provide Appropriate Dialysis Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident, identified as Resident 30, who required dialysis services. The facility's Hemodialysis Offsite Policy required staff to complete a Pre/Post Dialysis Communication Form to be sent with the resident to the dialysis clinic and completed upon their return. However, a review of these forms from July 2024 through October 2024 revealed multiple instances where the forms were not completed, specifically five times in July, ten times in August, ten times in September, and ten times in October. Staff 4, an LPN, confirmed that the forms were not consistently completed, and Staff 2, the DNS, acknowledged the failure to complete the forms on the identified dates. Additionally, the care plan for Resident 30 indicated that the resident had a right chest wall dialysis access site that required daily checks. However, there was no evidence in the medical record that these checks were performed. Resident 30 reported that staff did not assess the dialysis site after returning from dialysis. Staff 2 confirmed that the nursing staff were supposed to check the resident's chest and document it on the Treatment Administration Record (TAR), but acknowledged that there was no documentation of these checks in the TAR or the resident's medical record.
Failure to Address Pharmacy Recommendations for Two Residents
Penalty
Summary
The facility failed to ensure that pharmacist recommendations were considered for two residents, leading to a deficiency in medication management. Resident 14, who was admitted with a diagnosis of delusional disorder, was receiving haloperidol for psychosis related to metabolic encephalopathy and hallucinations. A pharmacy recommendation on 9/26/24 suggested a gradual dose reduction of haloperidol, as there were no episodes of delusions or hallucinations in the last three months. Although the physician signed off on the recommendation, it was not noted by the Director of Nursing Services (DNS) until 10/8/24, indicating a delay of 13 days in addressing the recommendation. Staff 2 acknowledged that the facility lacked a system to ensure timely addressing of pharmacy recommendations. Similarly, Resident 28, admitted with atrial fibrillation, had a pharmacy recommendation on 10/16/24 to update the medication order for Eliquis, which included outdated instructions related to a previous course of Paxlovid. The DNS did not recall receiving this recommendation and had to retrieve it online on 11/8/24, indicating that it had not been addressed in a timely manner. This oversight highlights the facility's failure to have an effective system in place to manage and implement pharmacy recommendations, potentially placing residents at risk for unnecessary medication.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to promptly respond to concerns raised during Resident Council meetings for two out of three months reviewed, which placed residents at risk for unresolved quality of life and care issues. The facility's policy, revised on 9/27/23, mandates that the facility must act promptly on recommendations from resident groups concerning care and life in the facility. The Activities Director is responsible for facilitating follow-up on suggestions and reporting results at the next meeting, with each Department Director required to fill out a comment form before the next meeting. However, the review of Resident Council Minutes from July to September 2024 revealed that there was no follow-up on residents' concerns and recommendations after the meetings held on 7/10/24 and 8/7/24. During the 7/10/24 meeting, residents expressed concerns about doors being closed without permission, call lights not being within reach, squeaking beds, and a lack of communication. In the 8/7/24 meeting, issues raised included the need for a cooler for food items, diet reports not being followed, rooms not being cleaned daily, and delays in call lights and medications. The 9/11/24 meeting also highlighted concerns about dietary preferences, diabetic options, clothing misplacement, and trash removal, with no follow-up from dietary and maintenance departments. Staff 3, the Activities Director, stated that she distributed meeting notes to department heads but did not receive responses. The Administrator, Staff 1, expected department managers to respond within seven to ten days, which did not occur.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Nursing homes near Mcminnville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Evan Terrace Post Acute | 1.2 mi | ★★★★★ | 2 | 0 |
| Village At Hillside | 2.3 mi | ★★★★★ | 6 | 0 |
| Chehalem Post Acute | 12.4 mi | ★★★★★ | 2 | 0 |
| Marquis Newberg | 13.2 mi | ★★★★★ | 6 | 0 |
| Rivers Edge Rehabilitation And Care | 13.3 mi | ★★★★★ | 21 | 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.