Above average — CMS composite of the measures below.
The next survey window likely opens around May 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 Mt Angel Health And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to complete annual performance reviews for 3 CNA staff members reviewed for sufficient and competent nurse staffing. Personnel record review showed the CNAs did not have completed evaluations, and the Administrator and DNS confirmed the missing reviews.
Improper disinfection of a shared glucometer was observed when an LPN returned from checking a resident’s CBG and placed the device in a drawer without disinfecting it. The facility policy and glucometer manual required EPA-approved disinfectant wipes, but the LPN stated she used alcohol pad wipes instead because she felt the EPA wipes were harsh. The DNS confirmed staff were to use approved EPA disinfectant wipes.
A resident with dementia, bipolar disorder, and HF was on hospice status, but the care plan did not identify the terminal illness as a focus area or include hospice/end-of-life interventions. The care plan only referenced hospice in limited areas such as ADL care, psychosocial support, activities, and anti-anxiety medication related to end of life. The DNS acknowledged the care plan was not revised to reflect the resident’s hospice status.
The facility failed to carry out ordered bowel care for two residents. One resident with chronic pain and heart failure went 5 days without a BM, with only docusate given and no other ordered bowel meds attempted. Another resident with kidney failure had two prolonged constipation episodes, including 11 days and 7 days without a BM; PRN laxatives and suppositories were given late or not at all, and staff acknowledged the resident was often on alert for not having a BM.
A resident with severe cognitive impairment, bilateral ROM impairments, and hand contractures was supposed to wear bilateral hand splints to help maintain ROM. Staff observed the resident's hands curled into fists while the splint was left on the bedside table, and a CNA admitted she forgot to offer the brace during her shift. An LPN said the resident tolerated the splints and allowed staff to apply them, while the RN Resident Care Manager was unsure why the splints were not worn consistently.
A resident's credit and debit cards were secured in a medication cart by an RN after the resident's death, but the cards went missing after an LPN took over the shift. The LPN displayed unusual behavior and did not return to work, and the cards were never recovered. Law enforcement and the resident's power of attorney were notified.
A resident with dementia and schizoaffective disorder received incorrect medications on two occasions due to staff errors. An RN and an LPN each administered medications intended for other residents, including clonazepam, Depakote, and Clozaril, among others. These errors were acknowledged by the staff, and the physician was notified.
The facility failed to provide written bed hold notifications to two residents or their representatives during hospital transfers. One resident, admitted with depression and diabetes, and another with anxiety and diabetes, were transferred multiple times without receiving the required notifications. Staff confirmed the absence of these notifications.
A resident with quadriplegia fell out of bed and fractured their shoulder due to inadequate supervision and failure to follow the care plan. An agency CNA, on her first shift, did not review the care plan and was misinformed about the resident's assistance needs. The CNA recognized the unsafe positioning but did not seek help, leading to the fall. The facility's DNS confirmed the fall was avoidable, citing lack of peer-to-peer reporting and care plan review as contributing factors.
A facility failed to address pressure ulcer risk factors in a resident's care plan, leading to a Stage 3 pressure injury from an ostomy belt. The resident, with a history of skin breakdown and pressure injuries, often refused ADL and ostomy care, which was not documented in the care plan. Staff reported the resident's ostomy belt was too tight, causing skin issues, and a risk versus benefit form was not completed to address care refusals.
The facility failed to protect a resident from sexual abuse by another resident. Despite staff interventions, the resident was inappropriately touched during breakfast, causing psychosocial harm and increased distress. The offending resident had a history of inappropriate sexual behavior and was supposed to be continuously supervised.
Missing Annual CNA Performance Reviews
Penalty
Summary
The facility failed to ensure annual performance evaluations were completed for 3 of 3 sampled CNA staff reviewed for sufficient and competent nurse staffing. A review of personnel records on 6/5/26 showed that Staff 11, hired in 12/2019, Staff 12, hired in 8/2013, and Staff 13, hired in 1/2019, did not have completed performance reviews. On 6/4/26 at 4:00 PM, the Administrator and DNS confirmed that annual performance reviews had not been completed for these three CNA staff members.
Improper Disinfection of Shared Glucometer
Penalty
Summary
The facility failed to properly disinfect a shared glucometer for 1 of 3 staff reviewed for infection control. The facility’s 12/2025 Glucometer Disinfection Policy required disinfection after each individual patient use with EPA disinfectant wipes, and the 2017 Evencare G2 glucometer manufacturer manual stated that common use glucometers were to be wiped with an approved disinfectant wipe and left wet for two minutes to ensure disinfection. Resident 81 was admitted in 11/2025 with diagnoses including diabetes. On 6/3/26 at 11:33 AM, Staff 5, the LPN Resident Care Manager, was observed returning to the medication cart after checking Resident 81’s CBG and placing the glucometer in the drawer without disinfecting it. Later that day, Staff 5 stated she used alcohol pad wipes to clean glucometers after checking residents’ CBGs and said EPA disinfectant wipes were harsh on the glucometer, so she preferred alcohol pad wipes. Staff 5 also stated she occasionally worked on all units in the facility. The DNS stated staff were to use approved EPA disinfectant wipes to disinfect the glucometers.
Care Plan Not Revised to Reflect Hospice Status
Penalty
Summary
The facility failed to revise a resident’s care plan to reflect hospice status and terminal illness for one sampled resident. The resident had diagnoses including dementia, bipolar disorder, and heart failure, and the 8/14/25 Significant Change MDS indicated hospice status. Review of the care plan showed hospice-related references for ADL care, psychosocial well-being, activities, and anti-anxiety medication related to end of life, but it did not identify the resident’s terminal illness as a focus area with interventions including hospice services or other end-of-life interventions. On 6/4/26, the DNS stated the expectation was for a terminal illness to be captured with interventions including hospice services on the care plan, and acknowledged the care plan was not revised to reflect the resident’s terminal illness and hospice status.
Failure to Provide Ordered Bowel Care Interventions
Penalty
Summary
The facility failed to implement ordered bowel care interventions for two residents who went extended periods without bowel movements. One resident, admitted with diagnoses including chronic pain and heart failure, had physician orders for multiple PRN bowel medications and a bowel care policy that called for Miralax after two days without a bowel movement, repeat Miralax and provider notification on day three, and a suppository with provider notification on day four. The resident had no bowel movement for five days, and the MAR showed only docusate was given on one day and documented as ineffective, with no other ordered bowel medication attempted. The Director of Nursing acknowledged the resident did not receive bowel care interventions in a timely manner and went five days without a bowel movement. A second resident, admitted with diagnoses including kidney failure, had scheduled bowel medications on Tuesdays, Thursdays, Saturdays, and Sundays, along with PRN Milk of Magnesia, Fleet enema, and bisacodyl suppository, with provider notification if no bowel movement occurred by day four. The resident had no bowel movement for 11 days and later for 7 days during the same month. The MAR showed Milk of Magnesia was given on day 7 of one episode and a suppository on day 12, with no additional PRN bowel medication provided; during the later episode, Milk of Magnesia was given on day 5 and no additional PRN bowel medication was provided. The resident stated having no bowel movement for over seven days caused abdominal discomfort, and staff acknowledged the resident went multiple shifts without a bowel movement and was often on alert for not having one.
Failure to Consistently Apply Hand Splints for ROM Support
Penalty
Summary
The facility failed to provide services to prevent further decrease in range of motion for Resident 17, who was admitted with osteomyelitis and whose 2/18/26 Quarterly MDS indicated a BIMS score of 00, severe cognitive impairment, inability to make daily decisions, dependence on staff for daily activities including applying splints, and bilateral upper and lower ROM impairments. The 3/19/26 care plan indicated the resident wore a left-hand carrot splint and a right-hand palm guard to help maintain ROM. During observations on 6/3/26 and 6/4/26, Resident 17's hands were curled into fists and could not be extended, and the resident was not wearing the hand splint, which was observed on top of the bedside table. The resident stated staff allowed the splint to be applied. Staff 8, a CNA, stated the resident's hand contractures were stiff and difficult to manage and admitted she did not offer to apply the brace during her shift because she forgot. Staff 9, an LPN, stated the resident used bilateral hand splints to prevent further decrease in ROM, tolerated them, and allowed staff to apply them, but staff did not tell her they were unable to apply the splint during the day. Staff 10, the RN Resident Care Manager, stated he was unsure why the resident did not wear the hand splint consistently and acknowledged the splints should be worn.
Failure to Protect Resident's Property from Misappropriation
Penalty
Summary
A resident with a diagnosis of diabetes was admitted to the facility in March 2024. After the resident passed away at the hospital, a registered nurse (RN) collected the resident's personal belongings, including six credit and debit cards, and secured them in the narcotic lock box within the medication cart. The RN informed the next nurse, an LPN, about the cards being locked in the cart. Subsequently, the cards went missing and were not found during a later check by the RN. Interviews and record reviews revealed that the LPN who took over the shift was acting unusually and did not return to work after the incident. Other staff members confirmed the LPN's odd behavior and lack of task completion during the shift. The resident's power of attorney was notified of the missing cards, and law enforcement was contacted. The facility administrator confirmed that the cards were missing and not recovered.
Medication Errors in Resident Care
Penalty
Summary
The facility failed to ensure physician orders were followed for a resident, leading to medication errors on two separate occasions. The first incident occurred when an RN administered medications intended for another resident to Resident 10, who had diagnoses including dementia and schizoaffective disorder. The medications administered in error included clonazepam, Depakote, docusate sodium, gabapentin, metoprolol, levothyroxine, and clozapine. The RN was unable to recall the name of the resident whose medications were mistakenly given to Resident 10. The second incident involved an LPN who administered medications intended for another resident to Resident 10. The medications given in error included clonazepam, Clozaril, lamotrigine, furosemide, and levothyroxine. Both incidents were acknowledged by the respective staff members involved, and the physician was notified of the errors. These errors placed the resident at risk for adverse medication side effects.
Failure to Provide Bed Hold Notifications
Penalty
Summary
The facility failed to provide written bed hold notifications to residents or their representatives at the time of transfer to the hospital, as required. This deficiency was identified for two residents who were reviewed for hospitalization. Resident 30, admitted in January 2023 with diagnoses including depression and diabetes, was transferred to the hospital on three occasions in 2024. No evidence was found in the resident's health record indicating that a written notice of the facility's bed hold policy was provided during these transfers. Similarly, Resident 38, admitted in August 2022 with diagnoses including anxiety and diabetes, was transferred to the hospital on three occasions in 2024. Again, there was no evidence of a written bed hold policy being provided. Staff confirmed the absence of these notifications for both residents during the identified transfers.
Avoidable Fall Due to Inadequate Supervision and Care Plan Review
Penalty
Summary
The facility failed to prevent an avoidable fall for a resident with quadriplegia and a Stage 4 pressure injury, who was cognitively intact and required assistance with activities of daily living (ADLs). The resident's care plan indicated the need for assistance from one or two staff members for repositioning and mobility. On the day of the incident, an agency CNA, who was working her first shift at the facility, did not review or have access to the care plan and was informed by a nurse that the resident required only one-person assistance for all ADL care needs. The CNA recognized the resident's unsafe positioning but did not seek additional help, leading to the resident falling out of bed and sustaining a right shoulder fracture. The fall investigation revealed that the CNA had multiple interactions with the resident and followed the care plan, but failed to request a second staff member for assistance when the resident's positioning was unsafe. The resident reported being pushed too close to the edge of the bed, resulting in the fall. The CNA stated that the resident refused repositioning before incontinence care, and when she went to gather supplies, the resident slid out of bed. The resident's right arm was caught in the side rail, and although initially not reporting pain, an X-ray later confirmed a fractured right shoulder. The facility's DNS confirmed the fall was avoidable and highlighted the lack of peer-to-peer reporting and care plan review during shift changes as contributing factors.
Failure to Address Pressure Ulcer Risk Factors in Care Plan
Penalty
Summary
The facility failed to adequately identify and address risk factors related to pressure ulcers in the care plan for a resident with a history of skin breakdown and pressure injuries. The resident, who was cognitively intact, had a colostomy and a history of skin issues, including a nonhealing skin graft and a wound around the stoma. Despite these conditions, the care plan did not reflect the resident's history of skin breakdown from the ostomy belt or their refusal of ADL and ostomy care. This oversight placed the resident at risk for further skin breakdown and pressure injuries. The resident had a pattern of refusing care, including ostomy changes and skin assessments, which contributed to the development of a Stage 3 pressure injury from the ostomy belt. Staff members reported that the resident often refused care, preferring to manage the ostomy bag independently, and would ask staff to return later if it was inconvenient. Despite being seen regularly at a wound clinic, the resident's care plan did not include a risk versus benefit form to document the refusals and potential consequences. Interviews with staff revealed that the resident's ostomy belt was often too tight, leading to skin breakdown. Staff were instructed to place pads under the belt to reduce friction, but this was not always effective. The facility's failure to document the resident's refusals and history of skin breakdown in the care plan, as well as the lack of a completed risk versus benefit form, contributed to the development of the pressure injury. The resident eventually stopped using the ostomy belt after the wound was discovered, and new treatment orders were implemented.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse by another resident. Resident 1, who had dementia and required 24-hour supervision, was inappropriately touched by Resident 2 during breakfast. Despite staff interventions, Resident 2 managed to touch Resident 1's private area, causing Resident 1 psychosocial harm and increased distress. Resident 2 had a history of inappropriate sexual behavior towards staff and was supposed to be continuously supervised in public spaces. On the day of the incident, Resident 2 was placed at a table away from other female residents but managed to move closer to Resident 1. Staff 5 observed Resident 2 rubbing Resident 1's thigh and intervened by moving Resident 2 to the hallway. However, Resident 2 returned to the table and was seen rubbing Resident 1's private area. Staff 3 and Staff 5 separated the residents again and took Resident 2 back to her/his room. Resident 1, who was unable to recall the incident due to her/his dementia, exhibited uncharacteristic behavior and expressed concern about someone sneaking into her/his room. The investigation revealed that Resident 2 had a history of sexually inappropriate behavior, including offering money to staff for sexual favors. Despite the care plan requiring two staff members to be present when interacting with Resident 2, the incident occurred, leading to Resident 1's distress. The facility's failure to adequately supervise Resident 2 and protect Resident 1 from sexual abuse was substantiated, resulting in a deficiency report.
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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 Mount Angel
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| French Prairie Nursing & Rehabilitation Center | 6.9 mi | ★★★★★ | 11 | 0 |
| Woodside Post Acute | 11.8 mi | ★★★★★ | 3 | 1 |
| Tierra Rose Care Center | 12 mi | ★★★★★ | 2 | 0 |
| Avamere Court At Keizer | 12.1 mi | ★★★★★ | 19 | 0 |
| Keizer Nursing And Rehabilitation | 12.1 mi | ★★★★★ | 3 | 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.