Cycle 1
Health 2024-08-30 · Fire 2024-08-30
22 health deficiencies
Top issue: Resident Rights (7 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Creswell, OR
Creswell Post Acute
2-star overall rating with 2-star inspections with 22 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
735 South 2nd Street, Creswell, OR
(541) 895-3333
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
76
Certified beds
Average residents
65
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1988-04-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.44
Registered nurse staffing
LPN hours / resident day
0.73
Licensed practical nurse staffing
Aide hours / resident day
2.85
Nurse aide staffing
Weekend hours
3.44
Weekend nurse staffing
RN turnover
63%
Annual RN turnover
Total nurse turnover
42%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.8% |
95.5%
1.3 pts better
|
93.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.2%
4.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
2.4%
1.3 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.7%
4.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 3.2% |
5.0%
1.8 pts better
|
5.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.6% |
12.5%
0.1 pts worse
|
19.6%
7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 8.6% |
14.7%
6.1 pts better
|
16.7%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 26.4% |
24.1%
2.3 pts worse
|
16.3%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.0% |
15.8%
3.8 pts better
|
14.9%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
1.7%
0.8 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.0%
2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.8% |
22.2%
1.4 pts better
|
19.8%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 5.5% |
6.5%
1 pts better
|
5.1%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 78.4% |
85.4%
7 pts worse
|
81.7%
3.3 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.8% |
15.1%
2.7 pts worse
|
12.0%
5.8 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.7% |
1.7%
1 pts worse
|
1.6%
1.1 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.5% |
81.2%
6.3 pts better
|
79.7%
7.8 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.3% |
21.6%
3.7 pts worse
|
23.9%
1.4 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-05 · Fire 2023-05-05
10 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-04-12 · Fire 2022-04-12
11 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-11-19
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2026-01-16
F · Potential for more than minimal harm
2025-11-19
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2026-01-16
F · Potential for more than minimal harm
2025-11-19
K700 · Miscellaneous Deficiencies
Fire Safety
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
Corrected 2026-01-16
F · Potential for more than minimal harm
2024-08-30
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-10-17
F · Potential for more than minimal harm
2024-08-30
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-17
F · Potential for more than minimal harm
2024-08-30
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-10-17
F · Potential for more than minimal harm
2022-04-12
K163 · Construction Deficiencies
Fire Safety
Install noncombustible or limited-combustible interior walls.
Corrected 2022-05-18
F · Potential for more than minimal harm
2022-04-12
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2022-05-18
F · Potential for more than minimal harm
2022-04-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-05-18
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-11
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-12-04
D · Potential for more than minimal harm
2025-12-11
F627 · Resident Rights Deficiencies
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2026-01-12
D · Potential for more than minimal harm
2025-12-11
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2026-01-12
D · Potential for more than minimal harm
2025-12-11
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2026-01-12
D · Potential for more than minimal harm
2025-12-11
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2026-01-12
E · Potential for more than minimal harm
2024-10-09
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-10-17
E · Potential for more than minimal harm
2024-08-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-17
E · Potential for more than minimal harm
2024-08-30
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-08-30
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-08-30
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-08-30
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-08-30
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-08-30
F585 · Resident Rights Deficiencies
Health
Honor 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.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-08-30
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-08-30
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-08-30
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-08-30
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-08-30
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-08-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-08-30
F688 · Quality of Life and Care Deficiencies
Health
Provide 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.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-08-30
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-08-30
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-08-30
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2024-10-17
E · Potential for more than minimal harm
2023-09-15
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-10-25
E · Potential for more than minimal harm
2023-09-15
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-10-25
D · Potential for more than minimal harm
2023-09-15
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-10-25
D · Potential for more than minimal harm
2023-09-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-25
D · Potential for more than minimal harm
2023-09-15
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-10-25
D · Potential for more than minimal harm
2023-09-15
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-10-25
D · Potential for more than minimal harm
2023-09-15
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-01-11
E · Potential for more than minimal harm
2023-05-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-24
E · Potential for more than minimal harm
2023-05-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-06-24
E · Potential for more than minimal harm
2023-05-05
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-06-24
D · Potential for more than minimal harm
2023-05-05
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2023-06-24
D · Potential for more than minimal harm
2023-05-05
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-06-24
D · Potential for more than minimal harm
2023-05-05
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-02-18
D · Potential for more than minimal harm
2023-05-05
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-06-24
D · Potential for more than minimal harm
2023-05-05
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-06-24
D · Potential for more than minimal harm
2023-05-05
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-06-24
D · Potential for more than minimal harm
2023-05-05
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-06-24
D · Potential for more than minimal harm
2023-05-05
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-06-24
D · Potential for more than minimal harm
2023-05-05
F849 · Administration Deficiencies
Health
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.
Corrected 2023-06-24
D · Potential for more than minimal harm
2022-04-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-05-18
Penalties and ownership
What sits behind the stars
Ownership
Providence Group Nh, LLC
5% Or Greater Direct Ownership Interest · Organization
Apt, Frederick
Operational/Managerial Control · Individual
Bookout, Jessica
Operational/Managerial Control · Individual
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Holman, Rick
Operational/Managerial Control · Individual
Jergensen, Joshua
Operational/Managerial Control · Individual
Mitchell, John
Operational/Managerial Control · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Truist Bank
5% Or Greater Security Interest · Organization
Wallenkampf, Victor
Operational/Managerial Control · Individual
Nearby options
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5-star overall rating with 5-star inspections with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
South Hills Rehabilitation Center
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1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $121,905 in total fines with 13 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Cascade Manor
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3-star overall rating with 4-star inspections with $10,033 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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