8 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Brookings, OR
2-star overall rating with 2-star inspections with abuse icon flag with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
1 Park Avenue, Brookings, OR
(541) 469-3111
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
59
Certified beds
Average residents
36
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Cascadia Healthcare
Operator or chain grouping
Approved since
1985-02-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
44 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.83
Registered nurse staffing · state 0.68 · national 0.68
LPN hours / resident day
0.58
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
3.01
Nurse aide staffing · state 3.37 · national 2.35
Total nurse hours
4.43
All reported nurse hours · state 4.95 · national 3.89
Licensed hours
1.41
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
3.90
Weekend nurse staffing · state 4.39 · national 3.43
Weekend RN hours
0.58
Weekend registered nurse coverage · state 0.44 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.90
CMS adjusted RN staffing hours
Adjusted total hours
4.80
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 53% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Program rank
718
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
64.98
Composite VBP score used to determine payment impact.
Payment multiplier
1.0193
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
10
Baseline 17.16% · Performance 15.97% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
5.36
Baseline 6.23% · Performance 6.23% · Measure score 5.36 · Achievement 5.36 · Improvement 0
Total nurse turnover
4.60
Baseline 50.00% · Performance 44.90% · Measure score 4.60 · Achievement 4.60 · Improvement 1.53
Adjusted total nurse staffing
6.04
Baseline 4.38 hours · Performance 4.80 hours · Measure score 6.04 · Achievement 6.04 · Improvement 2.45
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.71% |
10.72%
2 pts better
|
No Different than the National Rate · Eligible stays 188 · Observed rate 5.85% · Lower 95% interval 5.76% |
| Discharge to community | 55.93% |
50.57%
5.4 pts better
|
No Different than the National Rate · Eligible stays 209 · Observed rate 52.15% · Lower 95% interval 50.14% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 99.28% |
95.27%
4 pts better
|
Numerator 137 · Denominator 138 |
| Falls with major injury | 1.45% |
0.77%
0.7 pts worse
|
Numerator 2 · Denominator 138 |
| Discharge self-care score | 59.32% |
53.69%
5.6 pts better
|
Numerator 70 · Denominator 118 |
| Discharge mobility score | 46.61% |
50.94%
4.3 pts worse
|
Numerator 55 · Denominator 118 |
| Pressure ulcers or injuries, new or worsened | 5.8% |
2.29%
3.5 pts worse
|
Numerator 8 · Denominator 138 · Adjusted rate 6.21% |
| Healthcare-associated infections requiring hospitalization | 6.23% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 127 · Observed rate 4.72% · Lower 95% interval 4.17% |
| Staff COVID-19 vaccination coverage | 1.67% |
8.2%
6.5 pts worse
|
Numerator 1 · Denominator 60 |
| Staff flu vaccination coverage | 77.38% |
42%
35.4 pts better
|
Numerator 65 · Denominator 84 |
| Discharge function score | 64.41% |
56.45%
8 pts better
|
Numerator 76 · Denominator 118 |
| Transfer of health information to provider | 95% |
95.95%
1 pts worse
|
Numerator 19 · Denominator 20 |
| Transfer of health information to patient | 97.62% |
96.28%
1.3 pts better
|
Numerator 82 · Denominator 84 |
| Resident COVID-19 vaccinations up to date | 30.88% |
25.2%
5.7 pts better
|
Numerator 21 · Denominator 68 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.4
0.6 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 1.1 · Expected 2.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.1 |
2.5
1.6 pts worse
|
1.8
2.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.1 · Observed 5.0 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.5%
4.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 9.4% |
2.4%
7 pts worse
|
3.3%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 8.3% · Q3 12.0% · Q4 18.2% · 4Q avg 9.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.3% |
4.7%
2.4 pts better
|
11.4%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.5% · Q3 0.0% · Q4 5.0% · 4Q avg 2.3% |
| Percentage of long-stay residents who lose too much weight | 11.4% |
5.0%
6.4 pts worse
|
5.4%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 22.7% · Q3 13.6% · 4Q avg 11.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.6% |
12.5%
5.1 pts worse
|
19.6%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 17.4% · Q3 18.2% · 4Q avg 17.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.1% |
14.7%
5.6 pts better
|
16.7%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.1% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.3% |
15.8%
3.5 pts better
|
14.9%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 15.0% · 4Q avg 12.3% · Used in QM five-star |
| 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 · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
2.0%
0.9 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.7% |
22.2%
6.5 pts worse
|
19.8%
8.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 45.3% · 4Q avg 28.7% |
| Percentage of long-stay residents with pressure ulcers | 6.0% |
6.5%
0.5 pts better
|
5.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 4.2% · Q3 8.3% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.6% |
85.4%
12.2 pts better
|
81.7%
15.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.7% · Q2 100.0% · Q3 97.4% · Q4 94.8% · 4Q avg 97.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.9% |
15.1%
6.8 pts worse
|
12.0%
9.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 21.9% · Observed 18.8% · Expected 9.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.7%
0.3 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.2% · Q3 0.0% · Q4 1.5% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.6% |
81.2%
7.4 pts better
|
79.7%
8.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.9% |
21.6%
7.7 pts better
|
23.9%
10 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.9% · Observed 11.8% · Expected 20.2% · Used in QM five-star |
Survey summary
Top issue: Nutrition and Dietary (2 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Top issue: Resident Rights (7 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Top issue: Resident Rights (2 deficiencies)
9 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-03-13
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2025-03-13
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-13
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-13
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-11-01
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2023-11-01
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-11-01
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-11-01
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2022-09-16
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-09-16
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2022-09-16
Fire Safety
Ensure that suites are correctly sub-divided by noncombustible or limited-combustible construction.
Corrected 2022-09-16
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-09-16
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-09-16
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-09-16
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-09-16
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-09-16
Inspection history
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-09-26
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-13
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-03-13
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-03-13
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-03-13
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 2025-03-13
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-03-13
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-03-13
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-11-08
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 2023-11-08
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-11-08
Health
Implement a program that monitors antibiotic use.
Corrected 2023-11-08
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-11-08
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-11-08
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-11-08
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-11-08
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 2023-11-08
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2023-11-09
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-11-08
Health
Assess the resident when there is a significant change in condition
Corrected 2023-11-08
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-11-08
Health
Provide activities to meet all resident's needs.
Corrected 2023-11-08
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-08
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-11-08
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 2023-11-08
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-11-08
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-08
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2023-11-08
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-09-20
Health
Provide and implement an infection prevention and control program.
Corrected 2022-09-20
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-09-20
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-09-20
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-09-20
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-09-20
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
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3-star overall rating with 3-star inspections with $23,465 in total fines with 11 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
Grants Pass, OR
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