Cycle 1
Health 2024-10-09 · Fire 2024-10-09
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
13 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Madras, OR
East Cascade Retirement Community
3-star overall rating with 4-star inspections with $69,901 in total fines with 2 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
175 Ne 16th Street, Madras, OR
(541) 475-2273
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
20
Certified beds
Average residents
19
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1988-05-19
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
Hours and turnover
RN hours / resident day
0.32
Registered nurse staffing · state 0.68 · national 0.68
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.62
Nurse aide staffing · state 3.37 · national 2.35
Total nurse hours
0.94
All reported nurse hours · state 4.95 · national 3.89
Licensed hours
0.32
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
0.62
Weekend nurse staffing · state 4.39 · national 3.43
Weekend RN hours
0.07
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
0.30
CMS adjusted RN staffing hours
Adjusted total hours
0.87
CMS adjusted total nurse staffing hours
Case-mix index
1.49
Higher values indicate more complex resident acuity
RN turnover
86%
Annual RN turnover · state 53% · national 45%
Total nurse turnover
96%
Annual nurse turnover · state 49% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.18% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 26 · Observed rate 7.69% · Lower 95% interval 6.87% |
| Discharge to community | 41.28% |
50.57%
9.3 pts worse
|
No Different than the National Rate · Eligible stays 27 · Observed rate 29.63% · Lower 95% interval 28.19% |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 13 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 32 |
| Staff flu vaccination coverage | 36.73% |
42%
5.3 pts worse
|
Numerator 18 · Denominator 49 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.2% |
95.5%
0.3 pts worse
|
93.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 95.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
2.4%
2.4 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.7% |
4.7%
3 pts better
|
11.4%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.7% |
| Percentage of long-stay residents who lose too much weight | 4.0% |
5.0%
1 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.0% |
12.5%
5.5 pts worse
|
19.6%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 37.2% |
14.7%
22.5 pts worse
|
16.7%
20.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 37.2% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.4% |
15.8%
4.4 pts better
|
14.9%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.9% |
1.7%
2.2 pts worse
|
1.0%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 8.1% |
2.0%
6.1 pts worse
|
1.7%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.4% |
22.2%
1.2 pts worse
|
19.8%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.4% |
| Percentage of long-stay residents with pressure ulcers | 5.9% |
6.5%
0.6 pts better
|
5.1%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.7% |
85.4%
3.3 pts better
|
81.7%
7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 80.0% · Q2 90.5% · 4Q avg 88.7% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.7%
1.7 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.5% |
81.2%
9.3 pts better
|
79.7%
10.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.5% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-30 · Fire 2023-06-30
15 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
6 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Cycle 3
Health 2022-05-06 · Fire 2022-05-06
20 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
9 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-09
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-11-28
F · Potential for more than minimal harm
2024-10-09
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2024-11-28
F · Potential for more than minimal harm
2024-10-09
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-11-28
F · Potential for more than minimal harm
2024-10-09
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-11-28
F · Potential for more than minimal harm
2024-10-09
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-11-28
F · Potential for more than minimal harm
2024-10-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-28
F · Potential for more than minimal harm
2024-10-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-28
F · Potential for more than minimal harm
2024-10-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-28
F · Potential for more than minimal harm
2024-10-09
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-11-28
F · Potential for more than minimal harm
2024-10-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-28
D · Potential for more than minimal harm
2024-10-09
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-11-28
D · Potential for more than minimal harm
2024-10-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-28
D · Potential for more than minimal harm
2024-10-09
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-11-28
F · Potential for more than minimal harm
2023-06-30
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-08-10
F · Potential for more than minimal harm
2023-06-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-10
F · Potential for more than minimal harm
2023-06-30
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-10
F · Potential for more than minimal harm
2023-06-30
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-08-10
D · Potential for more than minimal harm
2023-06-30
K223 · Egress Deficiencies
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 2023-08-10
D · Potential for more than minimal harm
2023-06-30
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-08-10
F · Potential for more than minimal harm
2022-05-06
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-06-25
F · Potential for more than minimal harm
2022-05-06
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-06-25
F · Potential for more than minimal harm
2022-05-06
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-06-25
F · Potential for more than minimal harm
2022-05-06
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2022-06-25
F · Potential for more than minimal harm
2022-05-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-06-25
F · Potential for more than minimal harm
2022-05-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-06-25
F · Potential for more than minimal harm
2022-05-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-06-25
F · Potential for more than minimal harm
2022-05-06
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2022-06-25
D · Potential for more than minimal harm
2022-05-06
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-06-25
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-10-09
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-01
E · Potential for more than minimal harm
2024-10-09
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 2024-11-01
D · Potential for more than minimal harm
2024-07-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-08-02
G · Actual harm
2023-06-30
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-07-19
E · Potential for more than minimal harm
2023-06-30
F727 · Nursing and Physician Services Deficiencies
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 2023-08-10
E · Potential for more than minimal harm
2023-06-30
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2022-09-27
E · Potential for more than minimal harm
2023-06-30
F924 · Environmental Deficiencies
Health
Put firmly secured handrails on each side of hallways.
Corrected 2023-08-10
D · Potential for more than minimal harm
2023-06-30
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-08-10
D · Potential for more than minimal harm
2023-06-30
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 2023-08-10
D · Potential for more than minimal harm
2023-06-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-10
D · Potential for more than minimal harm
2023-06-30
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2023-08-10
D · Potential for more than minimal harm
2023-06-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-08-10
D · Potential for more than minimal harm
2023-06-30
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-08-10
D · Potential for more than minimal harm
2023-06-30
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 2023-08-10
D · Potential for more than minimal harm
2023-06-30
F758 · Pharmacy Service Deficiencies
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 2023-08-10
D · Potential for more than minimal harm
2023-06-30
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-08-10
D · Potential for more than minimal harm
2023-06-30
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2023-08-10
G · Actual harm
2022-05-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-06-25
G · Actual harm
2022-05-06
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-07-20
E · Potential for more than minimal harm
2022-05-06
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 2022-06-25
E · Potential for more than minimal harm
2022-05-06
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-06-25
E · Potential for more than minimal harm
2022-05-06
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 2022-06-25
E · Potential for more than minimal harm
2022-05-06
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2022-06-25
E · Potential for more than minimal harm
2022-05-06
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-06-25
E · Potential for more than minimal harm
2022-05-06
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-06-25
E · Potential for more than minimal harm
2022-05-06
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-06-25
D · Potential for more than minimal harm
2022-05-06
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-06-25
D · Potential for more than minimal harm
2022-05-06
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-06-25
D · Potential for more than minimal harm
2022-05-06
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 2022-06-25
D · Potential for more than minimal harm
2022-05-06
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 2022-06-25
D · Potential for more than minimal harm
2022-05-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-06-25
D · Potential for more than minimal harm
2022-05-06
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 2022-06-25
D · Potential for more than minimal harm
2022-05-06
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 2022-06-25
D · Potential for more than minimal harm
2022-05-06
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2022-06-25
D · Potential for more than minimal harm
2022-05-06
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2022-06-25
D · Potential for more than minimal harm
2022-05-06
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2022-06-25
D · Potential for more than minimal harm
2022-05-06
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-06-25
Penalties and ownership
What sits behind the stars
$69,901
2023-06-30
Fine
Fine · fine $69,901
Fine
Ownership
Cdk, LLC
5% Or Greater Direct Ownership Interest · Organization
Gill Family Trust
5% Or Greater Direct Ownership Interest · Organization
Mason, Christian
5% Or Greater Direct Ownership Interest · Individual
Ng, Peter
5% Or Greater Direct Ownership Interest · Individual
Braaksma, Judy
5% Or Greater Direct Ownership Interest · Individual
Judy, Ronald
5% Or Greater Direct Ownership Interest · Individual
Brownor Enterprises Inc
5% Or Greater Direct Ownership Interest · Organization
Bunza, Geoffrey
5% Or Greater Direct Ownership Interest · Individual
Ng, Kelvin
5% Or Greater Direct Ownership Interest · Individual
Aidan Health Services Inc
Operational/Managerial Control · Organization
Brown, Jana
5% Or Greater Direct Ownership Interest · Individual
Remley, Mark
Operational/Managerial Control · Individual
Remley, Mark
Contracted Managing Employee · Individual
Nearby options
Other facilities in reach
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Prineville, OR
4-star overall rating with 5-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Regency Redmond Rehabilitation And Nursing Center
Redmond, OR
4-star overall rating with 3-star inspections with $13,204 in total fines with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Bend Transitional Care
Bend, OR
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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